Healthcare Provider Details

I. General information

NPI: 1679646582
Provider Name (Legal Business Name): LAKE LOVELAND DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 BOISE AVE
LOVELAND CO
80538-4204
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 TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateCO

VIII. Authorized Official

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