Provider Demographics
NPI:1407836992
Name:VAN DAM, SCOTT D (DDS, MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:VAN DAM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7365
Mailing Address - Country:US
Mailing Address - Phone:605-348-6818
Mailing Address - Fax:
Practice Address - Street 1:3415 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7365
Practice Address - Country:US
Practice Address - Phone:605-348-6818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7080204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8000530Medicaid
SD8000530Medicaid
SDS101817Medicare PIN