Provider Demographics
NPI:1518597590
Name:SKELTON, PARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:PARK
Middle Name:
Last Name:SKELTON
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 1:930 DAVIS BND
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-1158
Mailing Address - Country:US
Mailing Address - Phone:404-435-3318
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 310
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3004
Practice Address - Country:US
Practice Address - Phone:404-435-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-18
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist