Healthcare Provider Details

I. General information

NPI: 1649379231
Provider Name (Legal Business Name): EASTSIDE DERMATOLOGY INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14030 NE 24TH ST SUITE 202
BELLEVUE WA
98007-3724
US

IV. Provider business mailing address

14030 NE 24TH ST SUITE 202
BELLEVUE WA
98007-3724
US

V. Phone/Fax

Practice location:
  • Phone: 425-454-1104
  • Fax: 425-454-1290
Mailing address:
  • Phone: 425-454-1104
  • Fax: 425-454-1290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELANIE A JENNINGS
Title or Position: OFFICE MANAGER
Credential:
Phone: 425-454-1104