Healthcare Provider Details

I. General information

NPI: 1073828786
Provider Name (Legal Business Name): SCOTT DENTAL GROUP L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 N UNION ST
LOUDONVILLE OH
44842-1074
US

IV. Provider business mailing address

633 N UNION ST
LOUDONVILLE OH
44842-1074
US

V. Phone/Fax

Practice location:
  • Phone: 419-994-3111
  • Fax: 419-994-4078
Mailing address:
  • Phone: 419-994-3111
  • Fax: 419-994-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number16373
License Number StateOH

VIII. Authorized Official

Name: DR. DARREL L SCOTT
Title or Position: OWNER
Credential: DDS
Phone: 419-994-3111