Provider Demographics
NPI:1356482657
Name:SKINNER, KEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:SKINNER
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 1:5651 STONE RD
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120
Mailing Address - Country:US
Mailing Address - Phone:703-830-3092
Mailing Address - Fax:703-830-0601
Practice Address - Street 1:5651 STONE RD
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120
Practice Address - Country:US
Practice Address - Phone:703-830-3092
Practice Address - Fax:703-830-0601
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014100551223G0001X
VAD401410055122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401410055OtherVIRGINIA STATE LICENSE