=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205002110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTT D ANDERSON DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 10/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 N MAIN ST
-----------------------------------------------------
City | GUNNISON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81230-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-641-4200
-----------------------------------------------------
Fax | 970-641-3262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 N MAIN ST
-----------------------------------------------------
City | GUNNISON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81230-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-641-4200
-----------------------------------------------------
Fax | 970-641-3262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MGR
-----------------------------------------------------
Name | JENNIFER R FLYNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-641-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8296
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8296
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------