Provider Demographics
NPI:1710028295
Name:ADVANCED DERMATOLOGIC SURGERY PA
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-420-0650
Mailing Address - Street 1:5310 HARVEST HILL RD SUITE 290
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-5826
Mailing Address - Country:US
Mailing Address - Phone:214-420-0650
Mailing Address - Fax:214-736-0512
Practice Address - Street 1:1213 HERMANN DR
Practice Address - Street 2:SUITE #650
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-7018
Practice Address - Country:US
Practice Address - Phone:713-528-8882
Practice Address - Fax:713-528-8883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207NS0135X
TXM6002207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00796ZMedicare PIN