Healthcare Provider Details

I. General information

NPI: 1578360665
Provider Name (Legal Business Name): VALLEY DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5702 W GLENDALE AVE
GLENDALE AZ
85301-2556
US

IV. Provider business mailing address

PO BOX 94765
PHOENIX AZ
85070-4765
US

V. Phone/Fax

Practice location:
  • Phone: 623-937-8969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KYLE SANNIEC
Title or Position: MANAGER
Credential: MD
Phone: 602-376-8638