Healthcare Provider Details

I. General information

NPI: 1972243780
Provider Name (Legal Business Name): HOUSE OF DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 ROSWELL ST STE 110
ALPHARETTA GA
30009-1979
US

IV. Provider business mailing address

5144 ARTEMESIA LN
DALLAS TX
75209-6242
US

V. Phone/Fax

Practice location:
  • Phone: 404-721-2418
  • Fax:
Mailing address:
  • Phone: 706-676-4836
  • 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 Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RAVI R PATEL
Title or Position: OWNER
Credential: MD
Phone: 706-676-4836