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General NPI Number Information
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NPI Number | 1487421988
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Entity Type | Organization
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Legal Business Name | DERMESURGE INC
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Dates
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Enumeration Date | 12/06/2023
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Last Update Date | 12/06/2023
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Provider Practice Location Address
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Address Line | 1111 GRAND AVE STE K
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City | DIAMOND BAR
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State | CA
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Zip | 91765-4172
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Country | US
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Telephone | 909-860-4254
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Fax | 98-602-6749
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Provider Business Mailing Address
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Address Line | 1111 GRAND AVE STE K
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City | DIAMOND BAR
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State | CA
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Zip | 91765-4172
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Country | US
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Telephone | 909-860-4254
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Fax | 98-602-6749
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Authorized Official
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Title or Position | CEO
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Name | SAM ABAZA
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Credential | MD
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Telephone | 909-860-4254
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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