Provider Demographics
NPI:1689662553
Name:SKINNER, JOHN P (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:SKINNER
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 1:4919 DIXIE HWY
Mailing Address - Street 2:SUITE J
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-2554
Mailing Address - Country:US
Mailing Address - Phone:502-449-3400
Mailing Address - Fax:502-449-3838
Practice Address - Street 1:4919 DIXIE HWY
Practice Address - Street 2:SUITE J
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2554
Practice Address - Country:US
Practice Address - Phone:502-449-3400
Practice Address - Fax:502-449-3838
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY64011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60064011Medicaid