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General NPI Number Information
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NPI Number | 1962871608
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Entity Type | Organization
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Legal Business Name | LAKES DERMATOLOGY, PA
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Dates
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Enumeration Date | 09/23/2015
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Last Update Date | 09/23/2015
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Provider Practice Location Address
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Address Line | 14305 SOUTHCROSS DR W SUITE 110
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City | BURNSVILLE
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State | MN
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Zip | 55306-7009
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Country | US
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Telephone | 612-387-4627
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Fax | 612-377-9713
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Provider Business Mailing Address
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Address Line | 2732 IRVING AVE S SUITE 110
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City | MINNEAPOLIS
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State | MN
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Zip | 55408-1049
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Country | US
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Telephone | 612-387-4627
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Fax | 612-377-9713
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Authorized Official
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Title or Position | DERMATOLOGIST, PRESIDENT
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Name | DR. REHANA LEILA AHMED-SAUCEDO
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Credential | MD, PHD
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Telephone | 612-387-4627
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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 | 51837
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License Number State | MN
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