Healthcare Provider Details

I. General information

NPI: 1205368453
Provider Name (Legal Business Name): DESTINATION DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MAIN STREET STE F, G & H
FRISCO CO
80443
US

IV. Provider business mailing address

400 N PARK AVE STE 12-B #1178
BRECKENRIDGE CO
80424
US

V. Phone/Fax

Practice location:
  • Phone: 309-287-1909
  • Fax:
Mailing address:
  • Phone: 970-409-4000
  • Fax: 855-839-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberPA0004388
License Number StateCO

VIII. Authorized Official

Name: KELLY ANN BALLOU
Title or Position: MANAGING MEMBER
Credential: PA-C
Phone: 970-409-4000