Healthcare Provider Details

I. General information

NPI: 1306263256
Provider Name (Legal Business Name): DALLAS DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 LAMAR AVE
PARIS TX
75460-5020
US

IV. Provider business mailing address

763 E US HIGHWAY 80 STE. 200
FORNEY TX
75126-8633
US

V. Phone/Fax

Practice location:
  • Phone: 903-204-4244
  • Fax: 903-905-4994
Mailing address:
  • Phone: 972-563-8500
  • Fax: 972-563-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberK8565
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberK8565
License Number StateTX

VIII. Authorized Official

Name: CANDACE WALDING
Title or Position: BILLING MANAGER
Credential:
Phone: 972-563-8500