Healthcare Provider Details

I. General information

NPI: 1528869500
Provider Name (Legal Business Name): EDWARD JOSEPH SKONIECZNY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 PARK RD
CHARLOTTE NC
28209-2272
US

IV. Provider business mailing address

4010 PARK RD
CHARLOTTE NC
28209-2272
US

V. Phone/Fax

Practice location:
  • Phone: 704-525-3939
  • Fax:
Mailing address:
  • Phone: 704-525-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14609
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: