Provider Demographics
NPI:1417934001
Name:DILWORTH DERMATOLOGY AND LASER, PLLC
Entity Type:Organization
Organization Name:DILWORTH DERMATOLOGY AND LASER, PLLC
Other - Org Name:DERMATOLOGIC LASER CENTER, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-376-9849
Mailing Address - Street 1:719 EAST BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:704-376-9849
Mailing Address - Fax:704-333-0708
Practice Address - Street 1:719 EAST BOULEVARD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-376-9849
Practice Address - Fax:704-333-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ND0101X
NC15596207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0229KOtherBCBS
NC2324401Medicare UPIN
NC2324401Medicare PIN