Healthcare Provider Details

I. General information

NPI: 1245587997
Provider Name (Legal Business Name): THOMAS EDWARD SKOUMAL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 RANDALL RD SUITE 105
GENEVA IL
60134-4209
US

IV. Provider business mailing address

302 RANDALL RD SUITE 105
GENEVA IL
60134-4209
US

V. Phone/Fax

Practice location:
  • Phone: 630-232-7385
  • Fax: 630-232-7389
Mailing address:
  • Phone: 630-232-7385
  • Fax: 630-232-7389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019029192
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number08978
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: