Healthcare Provider Details

I. General information

NPI: 1821298167
Provider Name (Legal Business Name): KOPRINCE DERMATOLOGY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 N MAIN ST
ROYAL OAK MI
48067-1835
US

IV. Provider business mailing address

713 N MAIN ST
ROYAL OAK MI
48067-1835
US

V. Phone/Fax

Practice location:
  • Phone: 248-548-7707
  • Fax: 248-548-7736
Mailing address:
  • Phone: 248-548-7707
  • Fax: 248-548-7736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PONE CHANTHAVONG
Title or Position: BILLER
Credential:
Phone: 248-548-7707