Provider Demographics
NPI:1760471106
Name:SKILLICORN, JOHN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:SKILLICORN
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 1:547 UNION ST S
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1817
Mailing Address - Country:US
Mailing Address - Phone:320-679-2464
Mailing Address - Fax:320-679-2101
Practice Address - Street 1:186 WESTWOOD CIR
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1731
Practice Address - Country:US
Practice Address - Phone:320-282-8463
Practice Address - Fax:320-679-2101
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND75191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN635017800Medicaid