Provider Demographics
NPI:1316151301
Name:SKLENICKA, SCOTT ROBERTS (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ROBERTS
Last Name:SKLENICKA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1473
Mailing Address - Country:US
Mailing Address - Phone:904-737-6799
Mailing Address - Fax:
Practice Address - Street 1:2511 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:SUITE 207
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-2346
Practice Address - Country:US
Practice Address - Phone:904-724-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN168521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program