Healthcare Provider Details

I. General information

NPI: 1912299504
Provider Name (Legal Business Name): CHRISTOS A SKOUTERIS D.M.D, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR MED INN ROOM C233A
ANN ARBOR MI
48109-5831
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-5963
  • Fax:
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901020344
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: