Provider Demographics
NPI:1487930384
Name:MINNICH, SCOTT JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JAMES
Last Name:MINNICH
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 1:8201 N CROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-9210
Mailing Address - Country:US
Mailing Address - Phone:989-681-4362
Mailing Address - Fax:
Practice Address - Street 1:8201 N CROSWELL RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-9210
Practice Address - Country:US
Practice Address - Phone:989-681-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist