Provider Demographics
NPI:1417163635
Name:SILVER FALLS DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:SILVER FALLS DERMATOLOGY, LLC
Other - Org Name:PACIFIC DERMATOLOGY AND COSMETIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-362-8385
Mailing Address - Street 1:PO BOX 741825
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-1825
Mailing Address - Country:US
Mailing Address - Phone:206-859-5777
Mailing Address - Fax:206-859-5776
Practice Address - Street 1:11011 MERIDIAN AVE N
Practice Address - Street 2:SUITE 102
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8967
Practice Address - Country:US
Practice Address - Phone:206-859-5777
Practice Address - Fax:206-859-5776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ND0101X, 207NS0135X
WAMD00042289261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00330265Medicare PIN
WAG8864732Medicare PIN