Provider Demographics
NPI:1508050923
Name:PROBST, SCOTT S (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:S
Last Name:PROBST
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 1:3820 PACIFIC AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7825
Mailing Address - Country:US
Mailing Address - Phone:253-472-3006
Mailing Address - Fax:253-472-3011
Practice Address - Street 1:3820 PACIFIC AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7825
Practice Address - Country:US
Practice Address - Phone:253-472-3006
Practice Address - Fax:253-472-3011
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9475DDS122300000X
WADE 60178653122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist