Provider Demographics
NPI:1093885311
Name:FAVERO, P. SCOTT (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:P. SCOTT
Middle Name:
Last Name:FAVERO
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 EUREKA RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3028
Mailing Address - Country:US
Mailing Address - Phone:916-782-2332
Mailing Address - Fax:
Practice Address - Street 1:1603 EUREKA RD
Practice Address - Street 2:SUITE 400
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3028
Practice Address - Country:US
Practice Address - Phone:916-782-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics