Provider Demographics
NPI:1174738462
Name:CHELGREN, SCOTT BRADLEY (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:BRADLEY
Last Name:CHELGREN
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 1:433 12TH PL N
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-2970
Mailing Address - Country:US
Mailing Address - Phone:425-774-8998
Mailing Address - Fax:
Practice Address - Street 1:560 QUILEUTE HEIGHTS
Practice Address - Street 2:
Practice Address - City:LAPUSH
Practice Address - State:WA
Practice Address - Zip Code:98350
Practice Address - Country:US
Practice Address - Phone:360-374-8659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084486Medicaid