Provider Demographics
NPI:1659656759
Name:LIBERTY DERMATOLOGY, PA
Entity Type:Organization
Organization Name:LIBERTY DERMATOLOGY, PA
Other - Org Name:LIBERTY DERMATOPATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-893-9677
Mailing Address - Street 1:PO BOX 601799
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75360-1799
Mailing Address - Country:US
Mailing Address - Phone:214-893-9677
Mailing Address - Fax:972-475-5303
Practice Address - Street 1:7105 LAKEVIEW PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4202
Practice Address - Country:US
Practice Address - Phone:972-475-5300
Practice Address - Fax:972-475-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3356207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty