Healthcare Provider Details

I. General information

NPI: 1053802785
Provider Name (Legal Business Name): GARRETT ALLEN SKONSENG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MAIN ST.
HAWLEY MN
56549
US

IV. Provider business mailing address

3431 18TH ST S
FARGO ND
58104-6538
US

V. Phone/Fax

Practice location:
  • Phone: 218-483-1038
  • Fax:
Mailing address:
  • Phone: 701-212-9390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14005
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: