Provider Demographics
NPI:1417581893
Name:SCOTT E BERDELLE DDS PC
Entity Type:Organization
Organization Name:SCOTT E BERDELLE DDS PC
Other - Org Name:DR SCOTT BERDELLE DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BERDELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-885-4343
Mailing Address - Street 1:1005 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-5012
Mailing Address - Country:US
Mailing Address - Phone:847-612-4323
Mailing Address - Fax:
Practice Address - Street 1:990 GRAND CANYON PKWY
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1739
Practice Address - Country:US
Practice Address - Phone:847-885-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-25
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty