Healthcare Provider Details

I. General information

NPI: 1003159385
Provider Name (Legal Business Name): SCOTT JEROME HUDEPOHL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 E 185TH ST
CLEVELAND OH
44119-2702
US

IV. Provider business mailing address

812 E 185TH ST
CLEVELAND OH
44119-2702
US

V. Phone/Fax

Practice location:
  • Phone: 216-481-9900
  • Fax:
Mailing address:
  • Phone: 216-481-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.024171
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: