Provider Demographics
NPI:1215113907
Name:BREWER, SCOT E (DMD)
Entity type:Individual
Prefix:
First Name:SCOT
Middle Name:E
Last Name:BREWER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 E JEFFERY DR
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-2750
Mailing Address - Country:US
Mailing Address - Phone:217-841-3035
Mailing Address - Fax:
Practice Address - Street 1:1208 E JEFFERY DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-2750
Practice Address - Country:US
Practice Address - Phone:217-841-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018558122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice