Healthcare Provider Details

I. General information

NPI: 1720814429
Provider Name (Legal Business Name): PINNACLE DERMATOLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 WAYZATA BLVD E STE 200
WAYZATA MN
55391-2513
US

IV. Provider business mailing address

PO BOX 734240
CHICAGO IL
60673-4240
US

V. Phone/Fax

Practice location:
  • Phone: 763-220-8030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSE LUIS RIOS
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 815-744-8554