Provider Demographics
NPI:1962626077
Name:NETTUM, SCOTT HOWARD (DDS)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:HOWARD
Last Name:NETTUM
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 1:6729 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:WI
Mailing Address - Zip Code:53598-0000
Mailing Address - Country:US
Mailing Address - Phone:608-846-5407
Mailing Address - Fax:608-846-2493
Practice Address - Street 1:6729 LAKE ROAD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:WI
Practice Address - Zip Code:53598-0000
Practice Address - Country:US
Practice Address - Phone:608-846-5407
Practice Address - Fax:608-846-2493
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50014501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice