Provider Demographics
NPI:1639313489
Name:AESTHETIC DERMATOLOGY, PC
Entity Type:Organization
Organization Name:AESTHETIC DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-205-0104
Mailing Address - Street 1:960 SANDERS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5962
Mailing Address - Country:US
Mailing Address - Phone:770-205-0104
Mailing Address - Fax:770-205-0975
Practice Address - Street 1:960 SANDERS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5962
Practice Address - Country:US
Practice Address - Phone:770-205-0104
Practice Address - Fax:770-205-0975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059398207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty