=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699836908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIAD DERMATOLOGY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 HIGHLAND OAKS DRIVE SUITE 106
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-2180
-----------------------------------------------------
Fax | 336-768-8031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 HIGHLAND OAKS DRIVE SUITE 106
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-2180
-----------------------------------------------------
Fax | 336-768-8031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DEBRA C LIU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 336-768-2180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 28663
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------