Healthcare Provider Details

I. General information

NPI: 1114089315
Provider Name (Legal Business Name): ANTHONY JOHN SKINNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 EXCELSIOR BLVD 180
ST LOUIS PARK MN
55426-4744
US

IV. Provider business mailing address

6600 EXCELSIOR BLVD 180
ST LOUIS PARK MN
55426-4744
US

V. Phone/Fax

Practice location:
  • Phone: 952-935-9009
  • Fax: 952-935-1006
Mailing address:
  • Phone: 952-935-9009
  • Fax: 952-935-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD11998
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: