Provider Demographics
NPI:1861455917
Name:PODLESH, SCOTT W (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:PODLESH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-7248
Mailing Address - Country:US
Mailing Address - Phone:650-969-7860
Mailing Address - Fax:
Practice Address - Street 1:885 SCOTT BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5255
Practice Address - Country:US
Practice Address - Phone:408-243-2300
Practice Address - Fax:408-243-2302
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADSO402940Medicare ID - Type UnspecifiedMEDICARE OUT OF NETWORK I