Healthcare Provider Details

I. General information

NPI: 1083713846
Provider Name (Legal Business Name): J. MICHAEL SKAHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 E KINGSLEY ST SUITE B
SPRINGFIELD MO
65804-7216
US

IV. Provider business mailing address

1320 E KINGSLEY ST SUITE B
SPRINGFIELD MO
65804-7216
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-5405
  • Fax:
Mailing address:
  • Phone: 417-881-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13354
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: