Healthcare Provider Details

I. General information

NPI: 1962219535
Provider Name (Legal Business Name): BLUE RIBBON DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N WATTERS RD STE 105
ALLEN TX
75013-5536
US

IV. Provider business mailing address

1150 N WATTERS RD STE 105
ALLEN TX
75013-5536
US

V. Phone/Fax

Practice location:
  • Phone: 469-331-3242
  • Fax: 469-331-3243
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. NADER ABOUL-FETTOUH
Title or Position: PHYSICIAN
Credential: MD
Phone: 469-331-3242