=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083181234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT BRENDAN DAIGLE DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2018
-----------------------------------------------------
Last Update Date | 10/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 FRANKLIN HEALTH CMNS UNIT 1
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04938-2052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-779-2659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 FRANKLIN HEALTH CMNS UNIT 1
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04938-5415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN4904
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1858165
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------