Provider Demographics
NPI:1417060856
Name:STANKE, SCOTT RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RICHARD
Last Name:STANKE
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 1:2050 MARQUETTE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1597
Mailing Address - Country:US
Mailing Address - Phone:815-224-4144
Mailing Address - Fax:815-224-4192
Practice Address - Street 1:2050 MARQUETTE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1597
Practice Address - Country:US
Practice Address - Phone:815-224-4144
Practice Address - Fax:815-224-4192
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics