Provider Demographics
NPI:1346957743
Name:MAZZULO, SCOTT JOSEPH
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:JOSEPH
Last Name:MAZZULO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11296 SE AQUILA ST
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7670
Mailing Address - Country:US
Mailing Address - Phone:704-909-8509
Mailing Address - Fax:
Practice Address - Street 1:10102 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4456
Practice Address - Country:US
Practice Address - Phone:704-909-8509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH8536124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist