1023344009 NPI number — DERMATOLOGY INSTITUTE AND LASER CENTER, LLC

Table of content: (NPI 1023344009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023344009 NPI number — DERMATOLOGY INSTITUTE AND LASER CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY INSTITUTE AND LASER CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1023344009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 CLIFTON AVE
Provider Second Line Business Mailing Address:
FLOOR 2 SUITE F
Provider Business Mailing Address City Name:
CLIFTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07013-3631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-925-9565
Provider Business Mailing Address Fax Number:
973-472-1300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 CLIFTON AVE
Provider Second Line Business Practice Location Address:
FLOOR 2 SUITE F
Provider Business Practice Location Address City Name:
CLIFTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07013-3631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-472-1000
Provider Business Practice Location Address Fax Number:
973-472-1300
Provider Enumeration Date:
10/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ROS
Authorized Official First Name:
ADRIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
DERMATOLOGIST
Authorized Official Telephone Number:
973-472-1000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  25MB08665600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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