Healthcare Provider Details

I. General information

NPI: 1629183397
Provider Name (Legal Business Name): RAYMOND A. SKINNER DDS, MS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E. MISSOURI #102
PHOENIX AZ
85014
US

IV. Provider business mailing address

1277 E. MISSOURI #102
PHOENIX AZ
85014
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-5896
  • Fax: 602-864-6114
Mailing address:
  • Phone: 602-266-5896
  • Fax: 602-864-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1924
License Number StateAZ

VIII. Authorized Official

Name: RAYMOND A SKINNER
Title or Position: PERIODONTIST
Credential: DDS
Phone: 602-266-5896