Healthcare Provider Details

I. General information

NPI: 1205880846
Provider Name (Legal Business Name): DERMATOLOGY AND SKIN CANCER SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 GRANADA LN
LEAWOOD KS
66211-1453
US

IV. Provider business mailing address

11550 GRANADA LN
LEAWOOD KS
66211-1453
US

V. Phone/Fax

Practice location:
  • Phone: 913-451-7546
  • Fax:
Mailing address:
  • Phone: 913-451-7546
  • 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: GLENN D GOLDSTEIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 913-451-7546