Provider Demographics
NPI:1215150693
Name:SCOVILLE, ANDREA MATLI (DDS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MATLI
Last Name:SCOVILLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-2601
Mailing Address - Country:US
Mailing Address - Phone:580-623-7121
Mailing Address - Fax:580-623-7124
Practice Address - Street 1:601 W 2ND STREET
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-2601
Practice Address - Country:US
Practice Address - Phone:580-623-7121
Practice Address - Fax:580-623-7124
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist