=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952420085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT ROGER MAKINS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 WALTON DR
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77840-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-696-8594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 FAIRFIELD CT
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-500-4224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 0012746
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------