Provider Demographics
NPI:1417585761
Name:GERGELIS, SCOTT RICHARD
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:RICHARD
Last Name:GERGELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 CHASEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1813
Mailing Address - Country:US
Mailing Address - Phone:716-913-0193
Mailing Address - Fax:
Practice Address - Street 1:110 CROSS KEYS OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3509
Practice Address - Country:US
Practice Address - Phone:585-223-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0638121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice