Healthcare Provider Details

I. General information

NPI: 1790732832
Provider Name (Legal Business Name): ARIZONA SKIN AND LASER THERAPY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 W NORTHERN AVE SUITE D-300
PHOENIX AZ
85021-4928
US

IV. Provider business mailing address

9900 N CENTRAL EXPY STE 500
DALLAS TX
75231-0928
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-1449
  • Fax: 602-277-9984
Mailing address:
  • Phone: 602-277-1449
  • Fax: 602-277-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: WILLIAM KO
Title or Position: MANAGING EMPLOYEE
Credential: MD
Phone: 602-277-1449