MEDICARE: DR. JUSTIN SKINNER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	13419926-9923	UT

General Provider Information

NPI Number	:	1083307359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN SKINNER DMD

Provider Business Mailing Address
First Line	:	2200 E 4500 S STE 100
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4032
Country	:	US
Telephone Number	:	801-845-6592
Fax Number	:

Provider Business Practice Location Address
First Line	:	2304 E 1700 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2721
Country	:	US
Telephone Number	:	801-845-6592
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2023
Last Update Date	:	06/01/2023

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