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General NPI Number Information
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NPI Number | 1275622664
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Entity Type | Organization
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Legal Business Name | NORTH BAY DERMATOLOGY ASSOCIATES
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 06/25/2019
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Provider Practice Location Address
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Address Line | 106 LYNCH CREEK WAY SUITE #8
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City | PETALUMA
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State | CA
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Zip | 94954-2356
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Country | US
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Telephone | 707-763-6816
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Fax | 707-763-1730
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Provider Business Mailing Address
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Address Line | 106 LYNCH CREEK WAY SUITE #8
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City | PETALUMA
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State | CA
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Zip | 94954-2356
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Country | US
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Telephone | 707-763-6816
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Fax | 707-763-1730
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Authorized Official
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Title or Position | PRACTICE OWNER
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Name | SANTIAGO CENTURION
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Credential | M.D.
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Telephone | 707-763-6816
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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 |
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License Number State |
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