Provider Demographics
NPI:1053578260
Name:OVERHOLSER, SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:OVERHOLSER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 N BROADWAY ST
Mailing Address - Street 2:LAKEVIEW DENTAL ARTS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4522
Mailing Address - Country:US
Mailing Address - Phone:773-270-5000
Mailing Address - Fax:872-206-5337
Practice Address - Street 1:3115 N BROADWAY ST
Practice Address - Street 2:LAKEVIEW DENTAL ARTS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4522
Practice Address - Country:US
Practice Address - Phone:773-270-5000
Practice Address - Fax:872-206-5337
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190262601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice