Healthcare Provider Details

I. General information

NPI: 1972467744
Provider Name (Legal Business Name): DECATUR DERMATOLOGY & AESTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E PONCE DE LEON AVE STE 150
DECATUR GA
30030-2566
US

IV. Provider business mailing address

216 GLENDALE AVE
DECATUR GA
30030-1918
US

V. Phone/Fax

Practice location:
  • Phone: 480-277-2656
  • Fax:
Mailing address:
  • Phone: 480-277-2656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLI BAENDER
Title or Position: OWNER
Credential: MD
Phone: 480-277-2656