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General NPI Number Information
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NPI Number | 1578360665
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Entity Type | Organization
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Legal Business Name | VALLEY DERMATOLOGY PLLC
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Dates
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Enumeration Date | 02/26/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 5702 W GLENDALE AVE
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City | GLENDALE
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State | AZ
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Zip | 85301-2556
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Country | US
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Telephone | 623-937-8969
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 94765
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City | PHOENIX
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State | AZ
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Zip | 85070-4765
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | KYLE SANNIEC
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Credential | MD
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Telephone | 602-376-8638
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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