Provider Demographics
NPI:1497337471
Name:COSMETIC SURGERY OF DFW PLLC
Entity Type:Organization
Organization Name:COSMETIC SURGERY OF DFW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-529-4314
Mailing Address - Street 1:800 12TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2519
Mailing Address - Country:US
Mailing Address - Phone:817-529-4314
Mailing Address - Fax:844-210-1095
Practice Address - Street 1:800 12TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2519
Practice Address - Country:US
Practice Address - Phone:817-529-4314
Practice Address - Fax:844-210-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty