MEDICARE: DR TINA L SKINNER DDS MS PC

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	122300000X	Dentist	9998	CO

General Provider Information

NPI Number	:	1346798923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR TINA L SKINNER DDS MS PC

Provider Business Mailing Address
First Line	:	2047 COLUMBIA DR
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81005-3279
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2047 COLUMBIA DR
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81005-3279
Country	:	US
Telephone Number	:	719-566-0206
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TINA SKINNER
Credential	:
Telephone Number	:	719-566-0206

Provider Enumeration Date	:	09/13/2016
Last Update Date	:	09/13/2016

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