Provider Demographics
NPI:1548236250
Name:MARDIS, SCOT C (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOT
Middle Name:C
Last Name:MARDIS
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 1:1616 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-2841
Mailing Address - Country:US
Mailing Address - Phone:812-232-8361
Mailing Address - Fax:812-238-9406
Practice Address - Street 1:1616 N 9TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2841
Practice Address - Country:US
Practice Address - Phone:812-232-8361
Practice Address - Fax:812-238-9406
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008116A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
777790OtherUNITED CONCORDIA