Provider Demographics
NPI:1467035204
Name:SKUTECKI, DENNIS P
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:P
Last Name:SKUTECKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W JACKSON ST # 274
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-2406
Mailing Address - Country:US
Mailing Address - Phone:703-651-6019
Mailing Address - Fax:
Practice Address - Street 1:209 W JACKSON ST # 274
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2406
Practice Address - Country:US
Practice Address - Phone:703-651-6019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD02848687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist