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General NPI Number Information
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NPI Number | 1497337471
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Entity Type | Organization
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Legal Business Name | COSMETIC SURGERY OF DFW PLLC
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Dates
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Enumeration Date | 04/28/2021
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Last Update Date | 04/28/2021
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Provider Practice Location Address
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Address Line | 800 12TH AVE STE 100
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City | FORT WORTH
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State | TX
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Zip | 76104-2519
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Country | US
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Telephone | 817-529-4314
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Fax | 844-210-1095
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Provider Business Mailing Address
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Address Line | 800 12TH AVE STE 100
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City | FORT WORTH
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State | TX
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Zip | 76104-2519
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Country | US
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Telephone | 817-529-4314
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Fax | 844-210-1095
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Authorized Official
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Title or Position | OWNER
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Name | DUSTIN DERRICK
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Credential | MD
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Telephone | 817-529-4314
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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