Basic Information
Provider Information | |||||||||
NPI: | 1457686297 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCOTT | ||||||||
FirstName: | YVONDIA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 WEST 8TH STREET | ||||||||
Address2: | SUITE 810 | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810033038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195624447 | ||||||||
FaxNumber: | 7195831801 | ||||||||
Practice Location | |||||||||
Address1: | 943-A S. IRBY | ||||||||
Address2: | HALLMARK SHOPPING CTR | ||||||||
City: | FLORENCE | ||||||||
State: | SC | ||||||||
PostalCode: | 295015217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9856413988 | ||||||||
FaxNumber: | 9856415182 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2009 | ||||||||
LastUpdateDate: | 03/19/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6015 | LA | N |   | Dental Providers | Dentist |   | 1223G0001X | 7115 | SC | Y |   | Dental Providers | Dentist | General Practice | 1223G0001X | 00401412800 | VA | N |   | Dental Providers | Dentist | General Practice |
No ID Information.