Provider Demographics
NPI:1285471052
Name:SCOTT, OCTAVIUS BERNARD (RDH)
Entity type:Individual
Prefix:
First Name:OCTAVIUS
Middle Name:BERNARD
Last Name:SCOTT
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BUGLE CALL DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-7930
Mailing Address - Country:US
Mailing Address - Phone:229-400-1796
Mailing Address - Fax:
Practice Address - Street 1:4300 DURAFORM LN
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:WI
Practice Address - Zip Code:53598-9671
Practice Address - Country:US
Practice Address - Phone:877-837-1918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14310124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist