Provider Demographics
NPI:1790245504
Name:SCOTTSBURG FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:SCOTTSBURG FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-243-4406
Mailing Address - Street 1:1366 N GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-7793
Mailing Address - Country:US
Mailing Address - Phone:812-752-3524
Mailing Address - Fax:
Practice Address - Street 1:1366 N GARDNER ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7793
Practice Address - Country:US
Practice Address - Phone:812-752-3524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty