Provider Demographics
NPI:1609051713
Name:BRODIE, SCOTT W (DMD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:BRODIE
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 1:305 SHAFER LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9681
Mailing Address - Country:US
Mailing Address - Phone:541-899-8833
Mailing Address - Fax:541-899-1769
Practice Address - Street 1:305 SHAFER LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9681
Practice Address - Country:US
Practice Address - Phone:541-899-8833
Practice Address - Fax:541-899-1769
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist