Provider Demographics
NPI:1790961670
Name:DERMATOLOGIC SURGERY OF THE CAROLINAS LLC
Entity Type:Organization
Organization Name:DERMATOLOGIC SURGERY OF THE CAROLINAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-302-3707
Mailing Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-919-1105
Mailing Address - Fax:704-910-3163
Practice Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Practice Address - Street 2:SUITE 225
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-919-1105
Practice Address - Fax:704-910-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2075624Medicare PIN