Provider Demographics
NPI:1477782076
Name:WATERSIDE DERMATOLOGY AND LASER CENTER PLLC
Entity Type:Organization
Organization Name:WATERSIDE DERMATOLOGY AND LASER CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:704-995-7941
Mailing Address - Street 1:7476 WATERSIDE LOOP RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-7679
Mailing Address - Country:US
Mailing Address - Phone:704-601-4381
Mailing Address - Fax:704-822-5997
Practice Address - Street 1:7476 WATERSIDE LOOP RD
Practice Address - Street 2:SUITE 600
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-7679
Practice Address - Country:US
Practice Address - Phone:704-601-4381
Practice Address - Fax:704-822-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912698Medicaid