Provider Demographics
NPI:1154434926
Name:SELF, SCOTT JEFFREY (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JEFFREY
Last Name:SELF
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:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-0607
Mailing Address - Country:US
Mailing Address - Phone:731-285-8890
Mailing Address - Fax:731-285-8790
Practice Address - Street 1:174 COMMUNITY PARK ROAD
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-285-8890
Practice Address - Fax:731-285-8790
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS7535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist