Healthcare Provider Details

I. General information

NPI: 1982829495
Provider Name (Legal Business Name): CRANBERRY SQUARE DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 ROUTE 134 SUITE 1A
SOUTH DENNIS MA
02660-3433
US

IV. Provider business mailing address

434 ROUTE 134 SUITE 1A
SOUTH DENNIS MA
02660-3433
US

V. Phone/Fax

Practice location:
  • Phone: 508-394-5556
  • Fax: 508-394-2735
Mailing address:
  • Phone: 508-394-5556
  • Fax: 508-394-2735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number80792
License Number StateMA

VIII. Authorized Official

Name: DR. AMY BETH KOFF
Title or Position: OWNER
Credential: M.D.
Phone: 508-394-5556