Provider Demographics
NPI:1629181482
Name:SCOTT, CORDELL NMN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CORDELL
Middle Name:NMN
Last Name:SCOTT
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 1:991 W HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-6430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4407
Practice Address - Country:US
Practice Address - Phone:704-735-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21351223G0001X
NC44011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
U39717Medicare UPIN
NC89901262Medicare ID - Type Unspecified