Healthcare Provider Details

I. General information

NPI: 1003955378
Provider Name (Legal Business Name): MAXIM V. SKORMIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 MAIN ST
HAMBURG NY
14075-4921
US

IV. Provider business mailing address

198 MAIN ST
HAMBURG NY
14075-4921
US

V. Phone/Fax

Practice location:
  • Phone: 716-649-5280
  • Fax: 716-649-5281
Mailing address:
  • Phone: 716-649-5280
  • Fax: 716-649-5281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number046024
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: