Provider Demographics
NPI:1992366892
Name:SCOTT, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
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 1:2509 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6922
Mailing Address - Country:US
Mailing Address - Phone:989-633-9811
Mailing Address - Fax:
Practice Address - Street 1:2509 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6922
Practice Address - Country:US
Practice Address - Phone:989-633-9811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist