Basic Information
| Provider Information | |||||||||
| NPI: | 1538189683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEADON | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | CLAYTON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | MACT HEALTH BOARD INC | ||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546262 | ||||||||
| FaxNumber: | 2097361814 | ||||||||
| Practice Location | |||||||||
| Address1: | 13975 MONO WAY SUITE I | ||||||||
| Address2: | MACT INDIAN DENTAL CLINIC | ||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953702824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095339603 | ||||||||
| FaxNumber: | 2095339604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 34440 | CA | Y | Dental Providers | Dentist | Dental Public Health |
No ID Information.