Provider Demographics
NPI:1003902909
Name:HELENA DERMATOLOGY & LASER CLINIC, P.C.
Entity Type:Organization
Organization Name:HELENA DERMATOLOGY & LASER CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LATHA
Authorized Official - Middle Name:SREE
Authorized Official - Last Name:VELLANKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-443-7200
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59624-1188
Mailing Address - Country:US
Mailing Address - Phone:406-443-7210
Mailing Address - Fax:406-443-7201
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8022
Practice Address - Country:US
Practice Address - Phone:406-443-7200
Practice Address - Fax:406-443-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000092195OtherBLUE CROSS BLUE SHIELD
MTDD8895OtherRAILROAD MEDICAR
MTDD8895OtherRAILROAD MEDICAR