Provider Demographics
NPI:1992879720
Name:TISDALE, SCOTT B (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:B
Last Name:TISDALE
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 1:31549 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082
Mailing Address - Country:US
Mailing Address - Phone:586-293-1530
Mailing Address - Fax:586-293-1537
Practice Address - Street 1:31549 HARPER AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082
Practice Address - Country:US
Practice Address - Phone:586-293-1530
Practice Address - Fax:586-293-1537
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist