Healthcare Provider Details

I. General information

NPI: 1407836992
Provider Name (Legal Business Name): SCOTT D VAN DAM DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 5TH ST
RAPID CITY SD
57701-7365
US

IV. Provider business mailing address

3415 5TH ST
RAPID CITY SD
57701-7365
US

V. Phone/Fax

Practice location:
  • Phone: 605-348-6818
  • Fax:
Mailing address:
  • Phone: 605-348-6818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number7080
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: