Healthcare Provider Details

I. General information

NPI: 1477696276
Provider Name (Legal Business Name): AESTHETIC DERMATOLOGY LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27995 GREENFIELD DR #C
LAGUNA NIGUEL CA
92677-4432
US

IV. Provider business mailing address

3055 W ORANGE AVE #207
ANAHEIM CA
92804-3159
US

V. Phone/Fax

Practice location:
  • Phone: 949-360-4400
  • Fax: 949-360-4200
Mailing address:
  • Phone: 714-229-8246
  • Fax: 714-229-9362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD MARK KRAMER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-360-4400