=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477782076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERSIDE DERMATOLOGY AND LASER CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2009
-----------------------------------------------------
Last Update Date | 02/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7476 WATERSIDE LOOP RD SUITE 600
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28037-7679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-601-4381
-----------------------------------------------------
Fax | 704-822-5997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7476 WATERSIDE LOOP RD SUITE 600
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28037-7679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-601-4381
-----------------------------------------------------
Fax | 704-822-5997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEBRA DIANE POWELL
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 704-995-7941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------