MEDICARE: MR. JOHN RANDOLPH SCOTT D.D.S.

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	6536	AZ

General Provider Information

NPI Number	:	1689716987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN RANDOLPH SCOTT D.D.S.

Provider Business Mailing Address
First Line	:	4033 ROMA RD
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8501
Country	:	US
Telephone Number	:	928-377-3314
Fax Number	:

Provider Business Practice Location Address
First Line	:	4626 W. ENGLISH DR.
Second Line	:	AZ DEPT. OF CORRECTIONS - KINGMAN
City	:	GOLDEN VALLEY
State	:	AZ
Zip	:	86413
Country	:	US
Telephone Number	:	928-565-2460
Fax Number	:	928-565-7043

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

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	07/08/2007

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