Provider Demographics
NPI:1205408630
Name:THE GALLERY OF DERMATOLOGY AND ADVANCED AESTHETICS
Entity Type:Organization
Organization Name:THE GALLERY OF DERMATOLOGY AND ADVANCED AESTHETICS
Other - Org Name:THE GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DAVIS-FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-564-7546
Mailing Address - Street 1:1936 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4131
Mailing Address - Country:US
Mailing Address - Phone:337-564-7546
Mailing Address - Fax:
Practice Address - Street 1:1936 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4131
Practice Address - Country:US
Practice Address - Phone:337-564-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty