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General NPI Number Information
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NPI Number | 1073792917
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Entity Type | Organization
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Legal Business Name | FAMILY DERMATOLOGY CENTER, P.C.
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Dates
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Enumeration Date | 10/29/2007
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Last Update Date | 10/29/2007
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Provider Practice Location Address
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Address Line | 20555 W. 12 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48076
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Country | US
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Telephone | 248-354-9595
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Fax | 248-354-9598
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Provider Business Mailing Address
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Address Line | P.O. BOX 3532
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City | SOUTHFIELD
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State | MI
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Zip | 48037
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Country | US
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Telephone | 248-354-9595
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Fax | 248-354-9598
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Authorized Official
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Title or Position | PRESIDENT
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Name | CAROL PRINCE
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Credential | M.D.
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Telephone | 248-354-9595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 4301038363
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License Number State | MI
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