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General NPI Number Information
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NPI Number | 1891879615
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Entity Type | Organization
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Legal Business Name | ESTHETICS CENTER FOR DERMATOLOGY PA
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 353 CLEMENT AVE
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City | CHARLOTTE
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State | NC
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Zip | 28204-2431
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Country | US
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Telephone | 704-370-2700
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Fax | 704-370-2702
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Provider Business Mailing Address
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Address Line | 353 CLEMENT AVE
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City | CHARLOTTE
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State | NC
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Zip | 28204-2431
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Country | US
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Telephone | 704-370-2700
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Fax | 704-370-2702
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Authorized Official
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Title or Position | OWNER
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Name | PEGGY A. FULLER
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Credential | M.D.
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Telephone | 704-370-2700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 127728
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License Number State | NC
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