Provider Demographics
NPI:1033133053
Name:SCOTT, ROBERT BENJAMIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BENJAMIN
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 WEST SPRINGFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4724
Mailing Address - Country:US
Mailing Address - Phone:217-352-5088
Mailing Address - Fax:
Practice Address - Street 1:805 W. SPRINGFIELD AVE.
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4724
Practice Address - Country:US
Practice Address - Phone:217-352-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190261691223G0001X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371117694OtherDME