Healthcare Provider Details

I. General information

NPI: 1427243476
Provider Name (Legal Business Name): MICHAEL ETHAN SKOLNICK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SOMME ST 2ND FLOOR
NEWARK NJ
07105-3612
US

IV. Provider business mailing address

515 SPRINGFIELD AVE
BERKELEY HEIGHTS NJ
07922-1180
US

V. Phone/Fax

Practice location:
  • Phone: 973-578-8788
  • Fax:
Mailing address:
  • Phone: 908-464-6789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02353600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number052662-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: