Provider Demographics
NPI:1356494264
Name:SKELTON, THERESA L (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
Last Name:SKELTON
Suffix:
Gender:F
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 S MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7055
Mailing Address - Country:US
Mailing Address - Phone:662-332-4902
Mailing Address - Fax:662-332-4994
Practice Address - Street 1:1540 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7055
Practice Address - Country:US
Practice Address - Phone:662-332-4902
Practice Address - Fax:662-332-4994
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOR370031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics