Provider Demographics
NPI:1972161420
Name:MICALLEF, SCOTT TREVOR (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:TREVOR
Last Name:MICALLEF
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 1:333 RICCIUTI DR APT 1307
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6295
Mailing Address - Country:US
Mailing Address - Phone:908-839-8313
Mailing Address - Fax:
Practice Address - Street 1:333 RICCIUTI DR APT 1307
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-6295
Practice Address - Country:US
Practice Address - Phone:908-839-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858373390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program