Provider Demographics
NPI:1821277872
Name:BULLOCH, SCOTT EDWIN (DDS MS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:EDWIN
Last Name:BULLOCH
Suffix:
Gender:M
Credentials:DDS MS
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Other - Credentials:
Mailing Address - Street 1:754 S MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-652-1445
Mailing Address - Fax:435-652-0138
Practice Address - Street 1:754 S MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-652-1445
Practice Address - Fax:435-652-0138
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT2735969224204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery