Healthcare Provider Details

I. General information

NPI: 1912912361
Provider Name (Legal Business Name): PREMIER DERMATOLOGY & SKIN RENEWAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SE 28TH ST STE 5
BENTONVILLE AR
72712-3880
US

IV. Provider business mailing address

909 SE 28TH ST STE 5
BENTONVILLE AR
72712-3880
US

V. Phone/Fax

Practice location:
  • Phone: 479-273-3376
  • Fax: 479-273-3468
Mailing address:
  • Phone: 479-273-3376
  • Fax: 479-273-3468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberE3363
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberE3363
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberE3363
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number StateAR

VIII. Authorized Official

Name: MR. JEFF CLIFTON
Title or Position: COO
Credential:
Phone: 479-273-3376