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General NPI Number Information
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NPI Number | 1851836928
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Entity Type | Organization
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Legal Business Name | PURE DERMATOLOGY CENTER
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 08/06/2019
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Provider Practice Location Address
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Address Line | 2005 WEST PARK DRIVE, SUITE 120
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City | IRVING
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State | TX
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Zip | 75061
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Country | US
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Telephone | 972-827-1130
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Fax | 972-597-4290
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Provider Business Mailing Address
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Address Line | 2005 W PARK DR STE 120
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City | IRVING
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State | TX
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Zip | 75061-2034
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Country | US
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Telephone | 972-827-1130
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Fax | 972-597-4290
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Authorized Official
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Title or Position | OWNER/MEDICAL DOCTOR
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Name | CAROLYN KIM
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Credential |
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Telephone | 972-827-1130
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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 | P7657
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License Number State | TX
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