Provider Demographics
NPI:1962416016
Name:SCOTT, TIMOTHY BRIAN (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRIAN
Last Name:SCOTT
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 1:716 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4160
Mailing Address - Country:US
Mailing Address - Phone:501-778-8201
Mailing Address - Fax:501-778-2841
Practice Address - Street 1:716 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4160
Practice Address - Country:US
Practice Address - Phone:501-778-8201
Practice Address - Fax:501-778-2841
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134921608Medicaid
AR5T783OtherBLUE CROSS BLUE SHIELD