Provider Demographics
NPI:1053609230
Name:SKRADSKI, JOSEPH L (DD,S)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
Last Name:SKRADSKI
Suffix:
Gender:M
Credentials:DD,S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12123 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154
Mailing Address - Country:US
Mailing Address - Phone:402-334-4422
Mailing Address - Fax:402-334-7167
Practice Address - Street 1:12123 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154
Practice Address - Country:US
Practice Address - Phone:402-334-4422
Practice Address - Fax:402-334-7167
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice