Healthcare Provider Details

I. General information

NPI: 1881099315
Provider Name (Legal Business Name): HIGHLAND DERMATOLOGY AND PLASTIC SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 OAK LAWN AVE SUITE 200
DALLAS TX
75219-4311
US

IV. Provider business mailing address

10743 PRESTON RD
DALLAS TX
75230-3806
US

V. Phone/Fax

Practice location:
  • Phone: 214-905-5075
  • Fax: 214-905-0903
Mailing address:
  • Phone: 214-905-5075
  • Fax: 214-905-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberF7235
License Number StateTX

VIII. Authorized Official

Name: BEN J TITTLE
Title or Position: OWNER
Credential: MD
Phone: 214-905-5075