Healthcare Provider Details

I. General information

NPI: 1902672652
Provider Name (Legal Business Name): BASE DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27776 WOODWARD AVE
ROYAL OAK MI
48067-0930
US

IV. Provider business mailing address

25504 SHERWOOD DR
HUNTINGTON WOODS MI
48070-1752
US

V. Phone/Fax

Practice location:
  • Phone: 248-355-5047
  • Fax: 248-355-3511
Mailing address:
  • Phone: 248-563-2489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRYAN SOFEN
Title or Position: OWNER
Credential: MD
Phone: 248-563-2489