Provider Demographics
NPI:1114366390
Name:HOUSE, DONALD SCOTT
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:SCOTT
Last Name:HOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10017 DESPERADO
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-6195
Mailing Address - Country:US
Mailing Address - Phone:208-520-0731
Mailing Address - Fax:
Practice Address - Street 1:121 EASTGATE PLZ
Practice Address - Street 2:
Practice Address - City:BELLMEAD
Practice Address - State:TX
Practice Address - Zip Code:76705-2868
Practice Address - Country:US
Practice Address - Phone:254-799-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX290611223G0001X
MI2901021867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist