Provider Demographics
NPI:1710213947
Name:DERMATOLOGY & SKIN CANCER PREVENTION CENTER, INC.
Entity Type:Organization
Organization Name:DERMATOLOGY & SKIN CANCER PREVENTION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-389-9116
Mailing Address - Street 1:1215 EAGLES LANDING PARKWAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7280
Mailing Address - Country:US
Mailing Address - Phone:770-389-9116
Mailing Address - Fax:770-506-4580
Practice Address - Street 1:1215 EAGLES LANDING PARKWAY
Practice Address - Street 2:SUITE 205
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7280
Practice Address - Country:US
Practice Address - Phone:770-389-9116
Practice Address - Fax:770-506-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052394174400000X
GA005538174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07BBSSPMedicare UPIN
GA202-G701235Medicare PIN
P1612Medicare UPIN