Provider Demographics
NPI:1366184947
Name:SKOUSEN, DEREK JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JOHN
Last Name:SKOUSEN
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 1:8218 LINDEMAN PASS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-2286
Mailing Address - Country:US
Mailing Address - Phone:415-980-9336
Mailing Address - Fax:
Practice Address - Street 1:59 DG-AF POSTGRADUATE DENTAL SCHOOL
Practice Address - Street 2:2133 PEPPERRELL STREET, BUILDING 3352
Practice Address - City:JBSA-LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:210-292-6258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011512122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist