Provider Demographics
NPI:1871757807
Name:SKYLES, RUSSEL LEE (DDS)
Entity type:Individual
Prefix:
First Name:RUSSEL
Middle Name:LEE
Last Name:SKYLES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E EVERGREEN AVE
Mailing Address - Street 2:SUITE 129
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3240
Mailing Address - Country:US
Mailing Address - Phone:847-259-7560
Mailing Address - Fax:847-259-0808
Practice Address - Street 1:200 E EVERGREEN AVE
Practice Address - Street 2:SUITE 129
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3240
Practice Address - Country:US
Practice Address - Phone:847-259-7560
Practice Address - Fax:847-259-0808
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0149851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice