Provider Demographics
NPI:1184667370
Name:DEROSSI, SCOTT S (DMD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:S
Last Name:DEROSSI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE, GC-1024
Mailing Address - Street 2:GHSU COLLEGE OF DENTAL MEDICINE
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-1001
Mailing Address - Country:US
Mailing Address - Phone:706-721-9633
Mailing Address - Fax:706-723-0266
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE, GC-1024
Practice Address - Street 2:GHSU COLLEGE OF DENTAL MEDICINE
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-9633
Practice Address - Fax:706-723-0266
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029512L204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016969200001Medicaid
U70931Medicare UPIN
PA010623Medicare ID - Type Unspecified