Provider Demographics
NPI:1033223565
Name:SCANTLEBURY, SOPHIA L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:L
Last Name:SCANTLEBURY
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PLAZA ST E
Mailing Address - Street 2:STE 1H
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4954
Mailing Address - Country:US
Mailing Address - Phone:718-230-5046
Mailing Address - Fax:
Practice Address - Street 1:10 PLAZA ST E
Practice Address - Street 2:STE 1H
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4954
Practice Address - Country:US
Practice Address - Phone:718-230-5046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0492791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31355933Medicaid