MEDICARE: DR. KIRK ALLEN SKIDMORE DDS

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	1223P0221X	Pediatric Dentistry	DE60232222	WA

General Provider Information

NPI Number	:	1144468703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIRK ALLEN SKIDMORE DDS

Provider Business Mailing Address
First Line	:	18008 STATE ROUTE 410 E
Second Line	:	SUITE B
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-7113
Country	:	US
Telephone Number	:	425-785-2641
Fax Number	:

Provider Business Practice Location Address
First Line	:	18008 STATE ROUTE 410 E
Second Line	:	SUITE B
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-7113
Country	:	US
Telephone Number	:	425-785-2641
Fax Number	:

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

Provider Enumeration Date	:	02/04/2009
Last Update Date	:	12/19/2014

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