Healthcare Provider Details

I. General information

NPI: 1417741414
Provider Name (Legal Business Name): PLYMOUTH DERMATOLOGY SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 COURT ST STE 201
PLYMOUTH MA
02360-4329
US

IV. Provider business mailing address

345 COURT ST STE 201
PLYMOUTH MA
02360-4329
US

V. Phone/Fax

Practice location:
  • Phone: 508-746-5300
  • Fax: 508-747-2001
Mailing address:
  • Phone: 508-746-5300
  • Fax: 508-747-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH YU
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 508-746-5300