Healthcare Provider Details

I. General information

NPI: 1316085764
Provider Name (Legal Business Name): SCOTT J. FERGUSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837 STABLE DR STE A
KIMBALL MI
48074-1441
US

IV. Provider business mailing address

2837 STABLE DRIVE STE A
KIMBALL MI
48074
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-3301
  • Fax:
Mailing address:
  • Phone: 810-985-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901015182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: