Provider Demographics
NPI:1801406731
Name:SKINNER, CALVIN TYLER (DDS)
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:TYLER
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 1:1306 CALLE VERONA APT 103
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1585
Mailing Address - Country:US
Mailing Address - Phone:208-987-0402
Mailing Address - Fax:
Practice Address - Street 1:674 BLVD DEFRANCE
Practice Address - Street 2:
Practice Address - City:MCRD PARRIS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29905
Practice Address - Country:US
Practice Address - Phone:843-228-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD11305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program