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General NPI Number Information
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NPI Number | 1578682373
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY LASER SURGERY CENTER INC.
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5 WENGER ROAD
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City | ENGLEWOOD
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State | OH
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Zip | 45322
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Country | US
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Telephone | 937-832-7555
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Fax | 937-830-2227
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Provider Business Mailing Address
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Address Line | 5 WENGER ROAD
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City | ENGLEWOOD
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State | OH
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Zip | 45322
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Country | US
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Telephone | 937-433-4922
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Fax | 937-433-6520
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Authorized Official
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Title or Position | MEDICAL DOCTOR PRES.
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Name | GARY D PALMER
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Credential | MD
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Telephone | 937-433-4922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | 35043172
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License Number State | OH
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