=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285416362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY AT THE LAKES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2023
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1114 HIGHWAY 59 S STE 1
-----------------------------------------------------
City | DETROIT LAKES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56501-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-802-1310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1114 HIGHWAY 59 S STE 1
-----------------------------------------------------
City | DETROIT LAKES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56501-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMANDA BEEHLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 415-802-1310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------