=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760712160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT BRADLY ESSIG DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2010
-----------------------------------------------------
Last Update Date | 01/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6801 S I H 35 STE 1-D
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78744-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-608-4420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2513 COUNTRYSIDE CIR
-----------------------------------------------------
City | SPICEWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78669-3046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-920-9509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25020
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------