Provider Demographics
NPI:1164696167
Name:PROVINCE, SCOTT CLIFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:CLIFFORD
Last Name:PROVINCE
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 1:317 MADISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:212-682-8032
Mailing Address - Fax:212-953-7049
Practice Address - Street 1:317 MADISON AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:212-682-8032
Practice Address - Fax:212-953-7049
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY47642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist