Healthcare Provider Details

I. General information

NPI: 1336752120
Provider Name (Legal Business Name): DAZZLING DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22029 STATE ROAD 7 STE 1
BOCA RATON FL
33428-4200
US

IV. Provider business mailing address

22029 STATE ROAD 7 STE 1
BOCA RATON FL
33428-4200
US

V. Phone/Fax

Practice location:
  • Phone: 561-923-0905
  • Fax:
Mailing address:
  • Phone: 561-923-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC W RUDNICK
Title or Position: OWNER/DERMATOLOGIST
Credential: MD
Phone: 561-923-0905