Provider Demographics
NPI:1114051521
Name:LASER VAGINAL REJUVENATION INSTITUTE OF DALLAS, P.A.
Entity Type:Organization
Organization Name:LASER VAGINAL REJUVENATION INSTITUTE OF DALLAS, P.A.
Other - Org Name:WOMEN'S WELLNESS INSTITUTE OF DALLAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-356-4616
Mailing Address - Street 1:9101 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5927
Mailing Address - Country:US
Mailing Address - Phone:214-356-4616
Mailing Address - Fax:
Practice Address - Street 1:9101 N CENTRAL EXPY
Practice Address - Street 2:SUITE 550
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5927
Practice Address - Country:US
Practice Address - Phone:214-356-4616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty