Basic Information
| Provider Information | |||||||||
| NPI: | 1750718193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WYETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 627 RANDALL RD | ||||||||
| Address2: | |||||||||
| City: | LUDLOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010561085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138580350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1049 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136931054 | ||||||||
| FaxNumber: | 4137319919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 08/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DL13996 | MA | Y | Dental Providers | Dentist |
No ID Information.