Provider Demographics
NPI:1235262684
Name:SCOTT, GARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:SCOTT
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 1:9021 N RODGERS CT SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-7649
Mailing Address - Country:US
Mailing Address - Phone:616-891-0004
Mailing Address - Fax:616-891-5170
Practice Address - Street 1:9021 N RODGERS CT SE
Practice Address - Street 2:SUITE E
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-7649
Practice Address - Country:US
Practice Address - Phone:616-891-0004
Practice Address - Fax:616-891-5170
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010169541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice