Basic Information
Provider Information
NPI: 1902119837
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BIETSCH
FirstName: SCOTT
MiddleName: MICHAEL
NamePrefix: DR.
NameSuffix:  
Credential: D.M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 577
Address2: 109 CALIFORNIA ST
City: CARTERVILLE
State: IL
PostalCode: 628180577
CountryCode: US
TelephoneNumber: 6189858221
FaxNumber:  
Practice Location
Address1: 402 S LEWIS LN
Address2:  
City: CARBONDALE
State: IL
PostalCode: 629013547
CountryCode: US
TelephoneNumber: 6185199200
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/20/2010
LastUpdateDate: 12/09/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X019.028399ILY Dental ProvidersDentist 
1223P0221X021002781ILN Dental ProvidersDentistPediatric Dentistry

No ID Information.


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