Provider Demographics
NPI:1346306107
Name:OKUBO, SCOTT REO (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:REO
Last Name:OKUBO
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:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:BRUCETON MILLS
Mailing Address - State:WV
Mailing Address - Zip Code:26525
Mailing Address - Country:US
Mailing Address - Phone:304-379-8101
Mailing Address - Fax:304-379-8102
Practice Address - Street 1:147 GREEN & MAIN
Practice Address - Street 2:
Practice Address - City:BRUCETON MILLS
Practice Address - State:WV
Practice Address - Zip Code:26519
Practice Address - Country:US
Practice Address - Phone:304-379-8101
Practice Address - Fax:304-379-8102
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134013000Medicaid