Healthcare Provider Details

I. General information

NPI: 1427501394
Provider Name (Legal Business Name): DIMMICK LAUGHLIN DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 E PRIMROSE ST STE D
SPRINGFIELD MO
65804-7910
US

IV. Provider business mailing address

1530 E PRIMROSE ST STE D
SPRINGFIELD MO
65804-7910
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-1818
  • Fax: 417-882-1821
Mailing address:
  • Phone: 417-882-1818
  • Fax: 417-882-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateMO

VIII. Authorized Official

Name: CATHERINE LAUGHLIN
Title or Position: AUTHORIZED REP/OWNER/MD
Credential:
Phone: 417-882-1818