Provider Demographics
NPI:1033109954
Name:SKIDMORE, TIMOTHY EMERSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EMERSON
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-4032
Mailing Address - Country:US
Mailing Address - Phone:815-399-7777
Mailing Address - Fax:
Practice Address - Street 1:39W250 HERRINGTON BLVD STE F1
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-208-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-22
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190258941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice