Provider Demographics
NPI:1477696466
Name:PEDIATRIC DERMATOLOGY OF DALLAS, PA
Entity Type:Organization
Organization Name:PEDIATRIC DERMATOLOGY OF DALLAS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:CARDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-580-1011
Mailing Address - Street 1:8315 WALNUT HILL LN STE 135
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4225
Mailing Address - Country:US
Mailing Address - Phone:214-580-1011
Mailing Address - Fax:214-580-1012
Practice Address - Street 1:9900 N CENTRAL EXPY
Practice Address - Street 2:SUITE #225
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4395
Practice Address - Country:US
Practice Address - Phone:214-384-7445
Practice Address - Fax:214-363-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH29966Medicare UPIN