Provider Demographics
NPI:1568907533
Name:ADVANCED DERMATOLOGY AND AESTHETIC CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY AND AESTHETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-371-7010
Mailing Address - Street 1:526 MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3301
Mailing Address - Country:US
Mailing Address - Phone:978-849-7537
Mailing Address - Fax:
Practice Address - Street 1:1 CITY HALL PLZ
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3149
Practice Address - Country:US
Practice Address - Phone:781-662-8881
Practice Address - Fax:781-662-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156364207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty