Provider Demographics
NPI:1356088967
Name:BICKNELL, SCOTT BERNARD
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:BERNARD
Last Name:BICKNELL
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 1:10900 W BLUEMOUND RD APT 215
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4145
Mailing Address - Country:US
Mailing Address - Phone:815-514-4005
Mailing Address - Fax:
Practice Address - Street 1:10757 W CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-3211
Practice Address - Country:US
Practice Address - Phone:414-203-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI6001070-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program