Healthcare Provider Details

I. General information

NPI: 1275622664
Provider Name (Legal Business Name): NORTH BAY DERMATOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 LYNCH CREEK WAY SUITE #8
PETALUMA CA
94954-2356
US

IV. Provider business mailing address

106 LYNCH CREEK WAY SUITE #8
PETALUMA CA
94954-2356
US

V. Phone/Fax

Practice location:
  • Phone: 707-763-6816
  • Fax: 707-763-1730
Mailing address:
  • Phone: 707-763-6816
  • Fax: 707-763-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: SANTIAGO CENTURION
Title or Position: PRACTICE OWNER
Credential: M.D.
Phone: 707-763-6816