Healthcare Provider Details

I. General information

NPI: 1700487675
Provider Name (Legal Business Name): LAKE LOVELAND DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OAKRIDGE DR
FORT COLLINS CO
80525-5528
US

IV. Provider business mailing address

PO BOX 7643
LOVELAND CO
80537-0643
US

V. Phone/Fax

Practice location:
  • Phone: 970-667-3116
  • Fax: 970-669-0159
Mailing address:
  • Phone: 970-663-2742
  • Fax: 970-342-2093

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 TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEVIN JOHN MOTT
Title or Position: OWNER
Credential: MD
Phone: 303-569-7700