Healthcare Provider Details

I. General information

NPI: 1215291414
Provider Name (Legal Business Name): DYSON DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 N BEVERLY AVE SUITE 101
TUCSON AZ
85712-2155
US

IV. Provider business mailing address

2141 N BEVERLY AVE SUITE 101
TUCSON AZ
85712-2155
US

V. Phone/Fax

Practice location:
  • Phone: 520-838-0777
  • Fax:
Mailing address:
  • Phone: 520-838-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number41383
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number41383
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number41383
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number41383
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number41383
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number41383
License Number StateAZ

VIII. Authorized Official

Name: DR. SENAIT W DYSON
Title or Position: OWNER
Credential: M.D.
Phone: 520-838-0777