Provider Demographics
NPI:1952791949
Name:SCOTT NIGL DENTAL PC
Entity Type:Organization
Organization Name:SCOTT NIGL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRM
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOLLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-273-8204
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:4216 24TH AVE
Practice Address - Street 2:STE 100
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3880
Practice Address - Country:US
Practice Address - Phone:810-984-8669
Practice Address - Fax:810-385-6157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI185641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty