Healthcare Provider Details

I. General information

NPI: 1295808491
Provider Name (Legal Business Name): RAYMOND SKINNER MS, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE SUITE 102
PHOENIX AZ
85014-2915
US

IV. Provider business mailing address

1277 E MISSOURI AVE SUITE, 102
PHOENIX AZ
85014-2915
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-5896
  • Fax: 602-274-6114
Mailing address:
  • Phone: 602-266-5896
  • Fax: 602-274-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD1924
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: