=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790732832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA SKIN AND LASER THERAPY INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2006
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2224 W NORTHERN AVE SUITE D-300
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85021-4928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-277-1449
-----------------------------------------------------
Fax | 602-277-9984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9900 N CENTRAL EXPY STE 500
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-0928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-277-1449
-----------------------------------------------------
Fax | 602-277-9984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING EMPLOYEE
-----------------------------------------------------
Name | WILLIAM KO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 602-277-1449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------