Provider Demographics
NPI:1710932454
Name:DAYTON SKIN SURGERY CENTER INC
Entity Type:Organization
Organization Name:DAYTON SKIN SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:B
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-293-5567
Mailing Address - Street 1:3025 GOVERNORS PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1330
Mailing Address - Country:US
Mailing Address - Phone:937-293-5567
Mailing Address - Fax:937-293-5568
Practice Address - Street 1:3025 GOVERNORS PLACE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1330
Practice Address - Country:US
Practice Address - Phone:937-293-5567
Practice Address - Fax:937-293-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073167207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9327881Medicare ID - Type Unspecified