=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043486707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS NICHOLAS SKARSHAUG DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2008
-----------------------------------------------------
Last Update Date | 05/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18209 SR 410 E SUITE 300
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391-5146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-826-8800
-----------------------------------------------------
Fax | 253-447-2203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18209 SR 410 E SUITE 300
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391-5146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-826-8800
-----------------------------------------------------
Fax | 253-447-2203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE00004546
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------