Provider Demographics
NPI:1417419409
Name:KOOPMAN, SCOTT J (DDS)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:KOOPMAN
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 1:3220 CHILI AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-5482
Mailing Address - Country:US
Mailing Address - Phone:585-889-2559
Mailing Address - Fax:
Practice Address - Street 1:3220 CHILI AVE STE 3
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-5482
Practice Address - Country:US
Practice Address - Phone:585-889-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY061380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program