Healthcare Provider Details

I. General information

NPI: 1346306107
Provider Name (Legal Business Name): SCOTT REO OKUBO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 GREEN & MAIN
BRUCETON MILLS WV
26519
US

IV. Provider business mailing address

PO BOX 147
BRUCETON MILLS WV
26525
US

V. Phone/Fax

Practice location:
  • Phone: 304-379-8101
  • Fax: 304-379-8102
Mailing address:
  • Phone: 304-379-8101
  • Fax: 304-379-8102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2976
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: