Healthcare Provider Details

I. General information

NPI: 1801282538
Provider Name (Legal Business Name): ROBERT SKILLICORN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 EUCLID AVE
CLEVELAND OH
44106
US

IV. Provider business mailing address

10900 EUCLID AVE
CLEVELAND OH
44106
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-3200
  • Fax:
Mailing address:
  • Phone: 216-368-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30.013366
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: