Provider Demographics
NPI:1760843494
Name:RADIANT DERMATOLOGY AND AESTHETICS PLLC
Entity Type:Organization
Organization Name:RADIANT DERMATOLOGY AND AESTHETICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIET
Authorized Official - Middle Name:N
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-973-4159
Mailing Address - Street 1:22659 HIGHWAY 59 N
Mailing Address - Street 2:SUITE 140
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-4406
Mailing Address - Country:US
Mailing Address - Phone:281-973-4159
Mailing Address - Fax:281-973-2359
Practice Address - Street 1:22659 HIGHWAY 59 N
Practice Address - Street 2:SUITE 140
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-4406
Practice Address - Country:US
Practice Address - Phone:281-973-4159
Practice Address - Fax:281-973-2359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7300207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty