Healthcare Provider Details

I. General information

NPI: 1881754224
Provider Name (Legal Business Name): UNIQUE DERMATOLOGY & WELLNESS CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 LYNX PAW TRL
VALRICO FL
33594-7426
US

IV. Provider business mailing address

4325 LYNX PAW TRL
VALRICO FL
33594-7426
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-9600
  • Fax: 813-662-9777
Mailing address:
  • Phone: 813-684-9600
  • Fax: 813-662-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberOS8642
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberOS8642
License Number StateFL

VIII. Authorized Official

Name: DR. DYAN JENELLE HARVEY-DENT
Title or Position: OWNER
Credential: D.O.
Phone: 813-684-9600