Provider Demographics
NPI:1780799361
Name:SUNTRUP, SCOTT CHRISTOPHER (DMD)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:CHRISTOPHER
Last Name:SUNTRUP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-2034
Mailing Address - Country:US
Mailing Address - Phone:618-662-5116
Mailing Address - Fax:618-403-5996
Practice Address - Street 1:217 E 2ND ST
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-2034
Practice Address - Country:US
Practice Address - Phone:618-662-5116
Practice Address - Fax:618-403-5996
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190272761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice