Provider Demographics
NPI:1588220677
Name:DANZL, SCOTT MICHAEL (DT)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:DANZL
Suffix:
Gender:M
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 CENTRAL PARK WAY UNIT 2418
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-2668
Mailing Address - Country:US
Mailing Address - Phone:651-249-1167
Mailing Address - Fax:
Practice Address - Street 1:393 DUNLAP ST N STE 308
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4223
Practice Address - Country:US
Practice Address - Phone:651-788-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT63125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist