=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942496880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED DERMATOLOGY AND LASER CENTER P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2007
-----------------------------------------------------
Last Update Date | 09/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 CLAIR DR
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29673-7771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-295-3376
-----------------------------------------------------
Fax | 864-295-9117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 CLAIR DR
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29673-7771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-295-3376
-----------------------------------------------------
Fax | 864-295-9117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. BEN M TREEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 864-295-3376
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 13943
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------