Healthcare Provider Details

I. General information

NPI: 1356884837
Provider Name (Legal Business Name): BRAVIA DERMATOLOGY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 SPRING MDWS DR W
HOLLAND OH
43528-7203
US

IV. Provider business mailing address

7050 SPRING MDWS DR W
HOLLAND OH
43528-7203
US

V. Phone/Fax

Practice location:
  • Phone: 419-948-3376
  • Fax: 419-665-3632
Mailing address:
  • Phone: 419-948-3376
  • Fax: 419-665-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW A MOLENDA
Title or Position: OWNER
Credential: MD
Phone: 419-948-3376