Provider Demographics
NPI:1740365964
Name:RISSER, SCOTT ELLIOT (DDS MSD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ELLIOT
Last Name:RISSER
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N NOTRE DAME AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617
Mailing Address - Country:US
Mailing Address - Phone:574-232-5866
Mailing Address - Fax:574-287-8891
Practice Address - Street 1:225 N NOTRE DAME AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617
Practice Address - Country:US
Practice Address - Phone:574-232-5866
Practice Address - Fax:574-287-8891
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120100631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics