1417934001 NPI number — DILWORTH DERMATOLOGY AND LASER, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417934001 NPI number — DILWORTH DERMATOLOGY AND LASER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DILWORTH DERMATOLOGY AND LASER, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DERMATOLOGIC LASER CENTER, PLLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417934001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
719 EAST BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-376-9849
Provider Business Mailing Address Fax Number:
704-333-0708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
719 EAST BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-376-9849
Provider Business Practice Location Address Fax Number:
704-333-0708
Provider Enumeration Date:
12/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SWARTZ
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
704-376-9849

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0229K . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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