Healthcare Provider Details

I. General information

NPI: 1114652831
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS OF ROCHESTER HILLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 N CANTON CENTER RD
CANTON MI
48187-5096
US

IV. Provider business mailing address

43151 DALCOMA DR STE 4
CLINTON TOWNSHIP MI
48038-6306
US

V. Phone/Fax

Practice location:
  • Phone: 734-495-1506
  • Fax: 734-495-1780
Mailing address:
  • Phone: 586-286-8720
  • Fax: 586-649-6699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIM VANHALL
Title or Position: SR. PROJECT MANAGER
Credential:
Phone: 586-286-8720