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General NPI Number Information
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NPI Number | 1679149702
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Entity Type | Organization
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Legal Business Name | REVIVAL DERMATOLOGY PLLC
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Dates
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Enumeration Date | 05/30/2021
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Last Update Date | 06/11/2021
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Provider Practice Location Address
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Address Line | 8201 PRESTON RD STE 440
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City | DALLAS
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State | TX
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Zip | 75225-6209
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Country | US
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Telephone | 214-675-3227
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Fax | 972-435-4481
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Provider Business Mailing Address
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Address Line | 8201 PRESTON RD STE 440
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City | DALLAS
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State | TX
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Zip | 75225-6209
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Country | US
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Telephone | 214-675-3227
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LISA GUIDRY PRUETT
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Credential | MD
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Telephone | 504-319-1407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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