Provider Demographics
NPI:1245737568
Name:TRIAD OCULAR AND FACIAL PLASTIC SURGERY PLLC
Entity Type:Organization
Organization Name:TRIAD OCULAR AND FACIAL PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:336-448-3060
Mailing Address - Street 1:5335 ROBINHOOD VILLAGE DR # 178
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-9820
Mailing Address - Country:US
Mailing Address - Phone:336-448-3060
Mailing Address - Fax:
Practice Address - Street 1:122 E KINDERTON WAY # B
Practice Address - Street 2:
Practice Address - City:BERMUDA RUN
Practice Address - State:NC
Practice Address - Zip Code:27006-7303
Practice Address - Country:US
Practice Address - Phone:336-448-3060
Practice Address - Fax:336-998-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01115207WX0200X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty