Healthcare Provider Details

I. General information

NPI: 1659656759
Provider Name (Legal Business Name): LIBERTY DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/10/2021
Certification Date: 10/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 LAKEVIEW PKWY STE 100
ROWLETT TX
75088-4202
US

IV. Provider business mailing address

PO BOX 601799
DALLAS TX
75360-1799
US

V. Phone/Fax

Practice location:
  • Phone: 972-475-5300
  • Fax: 972-475-5303
Mailing address:
  • Phone: 214-893-9677
  • Fax: 972-475-5303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN3356
License Number StateTX

VIII. Authorized Official

Name: KIEN T. TRAN
Title or Position: PRESIDENT
Credential: MD
Phone: 214-893-9677