MEDICARE: DR. JACOB WILLIAM SKINNER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN 16608	FL

General Provider Information

NPI Number	:	1063415040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB WILLIAM SKINNER DMD

Provider Business Mailing Address
First Line	:	13312 TIGER LILLY LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33625-3770
Country	:	US
Telephone Number	:	813-220-3372
Fax Number	:

Provider Business Practice Location Address
First Line	:	5121 EHRLICH RD
Second Line	:	STE 105
City	:	TAMPA
State	:	FL
Zip	:	33624-2015
Country	:	US
Telephone Number	:	813-960-2232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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