Provider Demographics
NPI:1306536586
Name:SKIDMORE, KEELY
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MONTGLEN CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6083
Mailing Address - Country:US
Mailing Address - Phone:864-884-8875
Mailing Address - Fax:
Practice Address - Street 1:220 N GROVE MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4222
Practice Address - Country:US
Practice Address - Phone:864-504-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2025-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC111691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice