Provider Demographics
NPI:1750392833
Name:SKINNER, BRETT T (DDS PC)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:T
Last Name:SKINNER
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E 200 N
Mailing Address - Street 2:STE E
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321
Mailing Address - Country:US
Mailing Address - Phone:435-792-3255
Mailing Address - Fax:435-792-3259
Practice Address - Street 1:150 E 200 N
Practice Address - Street 2:STE E
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:435-792-3255
Practice Address - Fax:435-792-3259
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49266789922122300000X
UT49266788903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1387225OtherUNITED CONCORDIA