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General NPI Number Information
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NPI Number | 1245737568
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Entity Type | Organization
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Legal Business Name | TRIAD OCULAR AND FACIAL PLASTIC SURGERY PLLC
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Dates
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Enumeration Date | 04/12/2018
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Last Update Date | 04/05/2019
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Provider Practice Location Address
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Address Line | 122 E KINDERTON WAY # B
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City | BERMUDA RUN
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State | NC
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Zip | 27006-7303
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Country | US
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Telephone | 336-448-3060
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Fax | 336-998-3333
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Provider Business Mailing Address
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Address Line | 5335 ROBINHOOD VILLAGE DR # 178
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City | WINSTON SALEM
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State | NC
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Zip | 27106-9820
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Country | US
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Telephone | 336-448-3060
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MOLLY LYNN FULLER
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Credential | MD, PHD
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Telephone | 336-448-3060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2082S0099X
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Taxonomy Name | Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician
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License Number | 2015-01115
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207WX0200X
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Taxonomy Name | Ophthalmic Plastic and Reconstructive Surgery Physician
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License Number | 2015-01115
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License Number State | NC
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