Provider Demographics
NPI:1598354995
Name:PREMIER DERMATOLOGY CLINIC LLC
Entity Type:Organization
Organization Name:PREMIER DERMATOLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-888-1177
Mailing Address - Street 1:3 PLAZA DR STE 17
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757-3765
Mailing Address - Country:US
Mailing Address - Phone:732-934-4141
Mailing Address - Fax:732-442-8886
Practice Address - Street 1:3 PLAZA DR STE 17
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08757-3765
Practice Address - Country:US
Practice Address - Phone:732-934-4141
Practice Address - Fax:732-442-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-12
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty