Provider Demographics
NPI:1841602612
Name:SCOTT, GRADY
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28811 S TAMIAMI TRL STE 14
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-3201
Mailing Address - Country:US
Mailing Address - Phone:239-947-5858
Mailing Address - Fax:
Practice Address - Street 1:28811 S TAMIAMI TRL STE 14
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-3201
Practice Address - Country:US
Practice Address - Phone:239-947-5858
Practice Address - Fax:239-947-4511
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist