Provider Demographics
NPI:1679637896
Name:SKINNER, ERIC S (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:S
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:PO BOX 17179
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-7179
Mailing Address - Country:US
Mailing Address - Phone:949-567-3176
Mailing Address - Fax:949-567-3185
Practice Address - Street 1:3150 N TENAYA WAY
Practice Address - Street 2:470
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0443
Practice Address - Country:US
Practice Address - Phone:702-869-0643
Practice Address - Fax:702-869-0643
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV29911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2202109Medicaid