Provider Demographics
NPI:1427243476
Name:SKOLNICK, MICHAEL ETHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ETHAN
Last Name:SKOLNICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-1180
Mailing Address - Country:US
Mailing Address - Phone:908-464-6789
Mailing Address - Fax:
Practice Address - Street 1:66 SOMME ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3612
Practice Address - Country:US
Practice Address - Phone:973-578-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI023536001223X0400X
NY052662-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics