Provider Demographics
NPI:1730235268
Name:SKIDMORE, ANGELA MARASCALCO (DDS)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:MARASCALCO
Last Name:SKIDMORE
Suffix:
Gender:F
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:PO BOX 1415
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936-1415
Mailing Address - Country:US
Mailing Address - Phone:901-872-8787
Mailing Address - Fax:479-252-6029
Practice Address - Street 1:4801 CUBA MILLINGTON RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-5401
Practice Address - Country:US
Practice Address - Phone:901-872-8787
Practice Address - Fax:479-252-6029
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN70831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN164632Medicaid