Provider Demographics
NPI:1457575094
Name:SCANTLAN, MARK ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:SCANTLAN
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 1:675 DUNSFORD DR
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-1267
Mailing Address - Country:US
Mailing Address - Phone:573-468-2774
Mailing Address - Fax:573-468-2008
Practice Address - Street 1:675 DUNSFORD DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1267
Practice Address - Country:US
Practice Address - Phone:573-468-2774
Practice Address - Fax:573-468-2008
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO14700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist