MEDICARE: SKINNER DENTAL

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1174395628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKINNER DENTAL

Provider Business Mailing Address
First Line	:	622 E 4500 S STE 101
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2922
Country	:	US
Telephone Number	:	801-313-1800
Fax Number	:	801-313-1803

Provider Business Practice Location Address
First Line	:	622 E 4500 S STE 101
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2922
Country	:	US
Telephone Number	:	801-313-1800
Fax Number	:	801-313-1803

Authorized Official
Title or Position	:	OWNER
Name	:	JASON DAVID SKINNER
Credential	:	DDS
Telephone Number	:	801-313-1800

Provider Enumeration Date	:	10/27/2023
Last Update Date	:	12/04/2024

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Directions to “SKINNER DENTAL ” Practice Location

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