Provider Demographics
NPI:1336397181
Name:NEISH, SCOTT RAYMOND (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:RAYMOND
Last Name:NEISH
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 1:1275 SW 158TH AVE.
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006
Mailing Address - Country:US
Mailing Address - Phone:503-641-1600
Mailing Address - Fax:503-643-4498
Practice Address - Street 1:1275 SW 158TH AVE.
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-641-1600
Practice Address - Fax:503-643-4498
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist