Provider Demographics
NPI:1184392607
Name:KNUREK, SCOTT
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:KNUREK
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 1:887 EATON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 WASHINGTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4350
Practice Address - Country:US
Practice Address - Phone:248-756-4910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016009531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice