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General NPI Number Information
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NPI Number | 1770386054
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Entity Type | Organization
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Legal Business Name | MODERN DERMATOLOGY, INC.
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Dates
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Enumeration Date | 03/31/2025
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 2921 PALO VERDE AVE # 102
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City | LONG BEACH
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State | CA
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Zip | 90815-1552
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Country | US
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Telephone | 678-779-2241
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Fax |
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Provider Business Mailing Address
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Address Line | 601 WAKEFIELD CT UNIT 103
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City | LONG BEACH
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State | CA
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Zip | 90803-7118
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Country | US
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Telephone | 678-779-2241
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. YOUNG KWAK
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Credential | MD
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Telephone | 678-779-2241
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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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