Provider Demographics
NPI:1124281407
Name:BERDELLE, SCOTT E
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:E
Last Name:BERDELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 GRAND CANYON PKWY
Mailing Address - Street 2:SUITE #410
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1739
Mailing Address - Country:US
Mailing Address - Phone:847-885-4343
Mailing Address - Fax:847-885-4382
Practice Address - Street 1:990 GRAND CANYON PKWY
Practice Address - Street 2:SUITE #410
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1739
Practice Address - Country:US
Practice Address - Phone:847-885-4343
Practice Address - Fax:847-885-4382
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190165941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice