Provider Demographics
NPI:1093868671
Name:WIRTH, SCOTT C (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:C
Last Name:WIRTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-1926
Mailing Address - Country:US
Mailing Address - Phone:262-377-0780
Mailing Address - Fax:
Practice Address - Street 1:1308 12TH AVE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-1926
Practice Address - Country:US
Practice Address - Phone:262-377-0780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001901-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice