MEDICARE: DR. CHARLES F. SCANLON II D.D.S., MSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4492	SC
2	1223P0300X	Periodontics	D0968	SD

General Provider Information

NPI Number	:	1568611374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES F. SCANLON II D.D.S., MSD

Provider Business Mailing Address
First Line	:	5955 SOUTH HIGHWAY 16
Second Line	:	SUITE A
City	:	RAPID CITY
State	:	SD
Zip	:	57701-8911
Country	:	US
Telephone Number	:	605-721-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	5955 SOUTH HIGHWAY 16
Second Line	:	SUITE A
City	:	RAPID CITY
State	:	SD
Zip	:	57701-8911
Country	:	US
Telephone Number	:	605-721-1111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2008
Last Update Date	:	04/17/2013

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Directions to “ DR. CHARLES F. SCANLON II D.D.S., MSD” Practice Location

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