Provider Demographics
NPI:1902061344
Name:TIMOTHY E. SKIDMORE, D.D.S., P.C.
Entity Type:Organization
Organization Name:TIMOTHY E. SKIDMORE, D.D.S., P.C.
Other - Org Name:MILL CREEK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:EMERSON
Authorized Official - Last Name:SKIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-208-0051
Mailing Address - Street 1:39W250 HERRINGTON BLVD
Mailing Address - Street 2:SUITE F1
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-6192
Mailing Address - Country:US
Mailing Address - Phone:630-208-0051
Mailing Address - Fax:
Practice Address - Street 1:39W250 HERRINGTON BLVD
Practice Address - Street 2:SUITE F1
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-6192
Practice Address - Country:US
Practice Address - Phone:630-208-0051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025894261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL189948Medicaid