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General NPI Number Information
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NPI Number | 1104068790
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Entity Type | Organization
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Legal Business Name | AESTHETIC DERMATOLOGY AND DERMATOLOGIC SURGERY CENTER
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Dates
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Enumeration Date | 03/30/2009
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Last Update Date | 08/27/2018
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Provider Practice Location Address
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Address Line | 4321 COLLINGTON RD SUITE 230
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City | BOWIE
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State | MD
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Zip | 20716
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Country | US
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Telephone | 301-809-4321
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Fax | 301-809-5798
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Provider Business Mailing Address
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Address Line | 4321 COLLINGTON RD SUITE 230
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City | BOWIE
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State | MD
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Zip | 20716-2259
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Country | US
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Telephone | 301-809-4321
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Fax | 301-809-5798
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DEBRA A COATS-WALTON
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Credential | MD
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Telephone | 301-809-4321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | D0051777
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License Number State | MD
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