Provider Demographics
NPI:1447618095
Name:SCOTT, KASSIE (MDT)
Entity Type:Individual
Prefix:
First Name:KASSIE
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MDT
Other - Prefix:
Other - First Name:KASSIE
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDT
Mailing Address - Street 1:968 WOODHILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:218-368-6546
Mailing Address - Fax:
Practice Address - Street 1:2251 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2486
Practice Address - Country:US
Practice Address - Phone:320-253-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT61125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist