Provider Demographics
NPI:1407384639
Name:STREET, SCOTT DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:STREET
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 1:10628 E 74TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-2540
Mailing Address - Country:US
Mailing Address - Phone:918-671-7345
Mailing Address - Fax:
Practice Address - Street 1:5510 E 41ST ST STE C
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6009
Practice Address - Country:US
Practice Address - Phone:918-347-6092
Practice Address - Fax:918-828-7364
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist