Healthcare Provider Details

I. General information

NPI: 1124166400
Provider Name (Legal Business Name): DERMATOLOGY & LASER CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 OLD NEWPORT BLVD SUITE 102
NEWPORT BEACH CA
92663-4269
US

IV. Provider business mailing address

401 OLD NEWPORT BLVD SUITE 102
NEWPORT BEACH CA
92663-4269
US

V. Phone/Fax

Practice location:
  • Phone: 949-631-0300
  • Fax: 949-631-0302
Mailing address:
  • Phone: 949-631-0300
  • Fax: 949-631-0302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA69586
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA69586
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA69586
License Number StateCA

VIII. Authorized Official

Name: DR. PAMELA HITE
Title or Position: CEO
Credential: M.D.
Phone: 949-631-0300