Provider Demographics
NPI:1093336257
Name:SKETTINI, MICHELLE PAULA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PAULA
Last Name:SKETTINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4203
Mailing Address - Country:US
Mailing Address - Phone:717-926-0099
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX392231223S0112X
PADS0448171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery