Healthcare Provider Details

I. General information

NPI: 1700996550
Provider Name (Legal Business Name): SCOT STROMSTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 WEST CENTRE AVE
PORTAGE MI
49024-5310
US

IV. Provider business mailing address

712 WEST CENTRE AVE
PORTAGE MI
49024-5310
US

V. Phone/Fax

Practice location:
  • Phone: 269-323-0335
  • Fax: 269-323-3396
Mailing address:
  • Phone: 269-323-0335
  • Fax: 269-323-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number012397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: