Healthcare Provider Details

I. General information

NPI: 1376230581
Provider Name (Legal Business Name): MODERN DERMATOLOGY AND COSMETIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 BELMAR BLVD
WALL NJ
07719-3948
US

IV. Provider business mailing address

2510 BELMAR BLVD
WALL NJ
07719-3948
US

V. Phone/Fax

Practice location:
  • Phone: 908-391-1694
  • Fax:
Mailing address:
  • Phone:
  • 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: IRIS HATZIMINAS
Title or Position: OWNER
Credential:
Phone: 908-391-1694