Provider Demographics
NPI:1164823274
Name:ENDRIZZI, SCOTT THEODORE (DMD, CAGS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:THEODORE
Last Name:ENDRIZZI
Suffix:
Gender:M
Credentials:DMD, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5124
Mailing Address - Country:US
Mailing Address - Phone:505-436-2727
Mailing Address - Fax:505-436-2737
Practice Address - Street 1:6600 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5124
Practice Address - Country:US
Practice Address - Phone:505-436-2727
Practice Address - Fax:505-436-2737
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD42021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics