Provider Demographics
NPI:1568749299
Name:DALLAS DERMATOLOGY
Entity Type:Organization
Organization Name:DALLAS DERMATOLOGY
Other - Org Name:GREENVILLE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-563-8500
Mailing Address - Street 1:763 E US HIGHWAY 80
Mailing Address - Street 2:STE. 200
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8633
Mailing Address - Country:US
Mailing Address - Phone:972-563-8500
Mailing Address - Fax:972-563-8501
Practice Address - Street 1:4724 WELLINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-4944
Practice Address - Country:US
Practice Address - Phone:972-563-8500
Practice Address - Fax:972-563-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8565207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty