Provider Demographics
NPI:1972039097
Name:AMUNDSON, SCOTT M (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:AMUNDSON
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 1:2600 DEMERS AVE
Mailing Address - Street 2:STE. 107
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4100
Mailing Address - Country:US
Mailing Address - Phone:701-772-0171
Mailing Address - Fax:
Practice Address - Street 1:212 S 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4776
Practice Address - Country:US
Practice Address - Phone:701-757-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND23061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice