Provider Demographics
NPI:1790956415
Name:DERMATOLOGY NORTHWEST LLC
Entity Type:Organization
Organization Name:DERMATOLOGY NORTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-544-2211
Mailing Address - Street 1:1845 W ORANGE GROVE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1134
Mailing Address - Country:US
Mailing Address - Phone:520-544-2211
Mailing Address - Fax:520-544-2277
Practice Address - Street 1:1845 W ORANGE GROVE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1134
Practice Address - Country:US
Practice Address - Phone:520-544-2211
Practice Address - Fax:520-544-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17914207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty