Healthcare Provider Details

I. General information

NPI: 1497749881
Provider Name (Legal Business Name): SCOTT W EDGAR DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 NE 2ND AVE #320
PORTLAND OR
97232-2064
US

IV. Provider business mailing address

2414 NE 32ND AVE
PORTLAND OR
97212-4933
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-0882
  • Fax: 503-231-9419
Mailing address:
  • Phone: 503-235-5796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD6981
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: