Provider Demographics
NPI:1528259678
Name:SKIDMORE, MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SKIDMORE
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 1:27699 JEFFERSON AVE
Mailing Address - Street 2:306
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2661
Mailing Address - Country:US
Mailing Address - Phone:951-506-2424
Mailing Address - Fax:951-506-0604
Practice Address - Street 1:27699 JEFFERSON AVE
Practice Address - Street 2:306
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2661
Practice Address - Country:US
Practice Address - Phone:951-506-2424
Practice Address - Fax:951-506-0604
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD73341223G0001X
CA565321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice