Provider Demographics
NPI:1689716987
Name:SCOTT, JOHN RANDOLPH (DDS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RANDOLPH
Last Name:SCOTT
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 1:4033 ROMA RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8501
Mailing Address - Country:US
Mailing Address - Phone:928-377-3314
Mailing Address - Fax:
Practice Address - Street 1:4626 W. ENGLISH DR.
Practice Address - Street 2:AZ DEPT. OF CORRECTIONS - KINGMAN
Practice Address - City:GOLDEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86413
Practice Address - Country:US
Practice Address - Phone:928-565-2460
Practice Address - Fax:928-565-7043
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice