Provider Demographics
NPI:1225764202
Name:POORTINGA, SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:POORTINGA
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 1:697 FRIARGATE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5624
Mailing Address - Country:US
Mailing Address - Phone:904-884-1188
Mailing Address - Fax:
Practice Address - Street 1:1403 DUNN AVE STE 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4870
Practice Address - Country:US
Practice Address - Phone:904-884-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN274031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN27403OtherFLORIDA DENTAL LICENSE NUMBER