Provider Demographics
NPI:1902119837
Name:BIETSCH, SCOTT MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:BIETSCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:109 CALIFORNIA ST
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62818-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:
Practice Address - Street 1:402 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.028399122300000X
IL0210027811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL640701Medicare PIN