Provider Demographics
NPI:1760495352
Name:DALLAS DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:DALLAS DERMATOLOGY, LLC
Other - Org Name:FORNEY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-563-8500
Mailing Address - Street 1:763 E US HIGHWAY 80
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8633
Mailing Address - Country:US
Mailing Address - Phone:972-563-8500
Mailing Address - Fax:972-563-8501
Practice Address - Street 1:763 E US HIGHWAY 80
Practice Address - Street 2:SUITE 200
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8633
Practice Address - Country:US
Practice Address - Phone:972-563-8500
Practice Address - Fax:972-563-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8565207N00000X, 207NS0135X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00113YMedicare ID - Type Unspecified