Healthcare Provider Details

I. General information

NPI: 1376917633
Provider Name (Legal Business Name): DILWORTH FACIAL PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 LYNDHURST AVE
CHARLOTTE NC
28203-5103
US

IV. Provider business mailing address

1819 LYNDHURST AVE
CHARLOTTE NC
28203-5103
US

V. Phone/Fax

Practice location:
  • Phone: 980-949-6544
  • Fax: 980-422-0091
Mailing address:
  • Phone: 980-949-6544
  • Fax: 980-422-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2013-00940
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number2013-00940
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2013-00940
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number2013-00940
License Number StateNC

VIII. Authorized Official

Name: JOSHUA B SUROWITZ
Title or Position: CO-OWNER
Credential: M.D.
Phone: 919-619-0383