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General NPI Number Information
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NPI Number | 1205408630
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Entity Type | Organization
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Legal Business Name | THE GALLERY OF DERMATOLOGY AND ADVANCED AESTHETICS
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Dates
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Enumeration Date | 07/14/2021
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Last Update Date | 07/14/2021
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Provider Practice Location Address
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Address Line | 1936 SOUTHWOOD DR
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4131
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Country | US
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Telephone | 337-564-7546
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Fax |
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Provider Business Mailing Address
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Address Line | 1936 SOUTHWOOD DR
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4131
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Country | US
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Telephone | 337-564-7546
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KERRI ELIZABETH DAVIS-FONTENOT
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Credential | MD
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Telephone | 337-564-7546
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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 |
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License Number State |
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