Provider Demographics
NPI:1508059817
Name:HALLSTED, SCOTT CLINTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:CLINTON
Last Name:HALLSTED
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 1:500 PRIMROSE RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3907
Mailing Address - Country:US
Mailing Address - Phone:650-343-1104
Mailing Address - Fax:650-343-0772
Practice Address - Street 1:500 PRIMROSE RD
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3907
Practice Address - Country:US
Practice Address - Phone:650-343-1104
Practice Address - Fax:650-343-0772
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA231901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6731900001Medicare NSC