Provider Demographics
NPI:1497749881
Name:EDGAR, SCOTT W (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:EDGAR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 NE 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4933
Mailing Address - Country:US
Mailing Address - Phone:503-235-5796
Mailing Address - Fax:
Practice Address - Street 1:1020 NE 2ND AVE
Practice Address - Street 2:#320
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2064
Practice Address - Country:US
Practice Address - Phone:503-231-0882
Practice Address - Fax:503-231-9419
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69811223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics