Healthcare Provider Details

I. General information

NPI: 1295579555
Provider Name (Legal Business Name): CLEMMONS DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 LEWISVILLE CLEMMONS RD
CLEMMONS NC
27012-8712
US

IV. Provider business mailing address

2515 LEWISVILLE CLEMMONS RD
CLEMMONS NC
27012-8712
US

V. Phone/Fax

Practice location:
  • Phone: 336-416-4093
  • Fax:
Mailing address:
  • Phone: 336-416-4093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BETH ANN GURLEY
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 336-979-4499