Provider Demographics
NPI:1689744898
Name:SKINNER, JASON T (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
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 1:102 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-1803
Mailing Address - Country:US
Mailing Address - Phone:641-357-4112
Mailing Address - Fax:641-357-0670
Practice Address - Street 1:102 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-1803
Practice Address - Country:US
Practice Address - Phone:641-357-4112
Practice Address - Fax:641-357-0670
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0205708Medicaid