Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 13354 | MO |
NPI | 1083713846 |
---|---|
Provider Name | Dr. J. Michael Skahan |
First Address | Springfield, MO 65804-7216 |
Second Address | Springfield, MO 65804-7216 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2006 |
Last Update Date | 08/07/2007 |