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General NPI Number Information
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NPI Number | 1366184947
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Entity Type | Individual
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Provider Name | DEREK JOHN SKOUSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 04/12/2022
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Last Update Date | 07/23/2025
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Provider Practice Location Address
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Address Line | 59 DG-AF POSTGRADUATE DENTAL SCHOOL 2133 PEPPERRELL STREET, BUILDING 3352
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City | JBSA-LACKLAND
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State | TX
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Zip | 78236-5313
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Country | US
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Telephone | 210-292-6258
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Fax |
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Provider Business Mailing Address
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Address Line | 8218 LINDEMAN PASS
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City | SAN ANTONIO
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State | TX
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Zip | 78254-2286
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Country | US
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Telephone | 415-980-9336
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D011512
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License Number State | AZ
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