Provider Demographics
NPI:1912218876
Name:SCOTT, DONTRA BRANDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONTRA
Middle Name:BRANDON
Last Name:SCOTT
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 1:1114 CAMINO LA COSTA
Mailing Address - Street 2:3079
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-3334
Mailing Address - Country:US
Mailing Address - Phone:410-258-3869
Mailing Address - Fax:718-901-8121
Practice Address - Street 1:11901 TOEPPERWEIN RD
Practice Address - Street 2:902
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3161
Practice Address - Country:US
Practice Address - Phone:410-258-3869
Practice Address - Fax:718-901-8121
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY056528-1122300000X
TX302271223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist