Provider Demographics
NPI:1912069840
Name:SKIDMORE, LANCE J (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:J
Last Name:SKIDMORE
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 W BEAUREGARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3813
Mailing Address - Country:US
Mailing Address - Phone:325-716-9597
Mailing Address - Fax:
Practice Address - Street 1:2014 W BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3813
Practice Address - Country:US
Practice Address - Phone:325-716-9597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX237881223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics