Provider Demographics
NPI:1821298167
Name:KOPRINCE DERMATOLOGY PLC
Entity Type:Organization
Organization Name:KOPRINCE DERMATOLOGY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:PONE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANTHAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-548-7707
Mailing Address - Street 1:713 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1835
Mailing Address - Country:US
Mailing Address - Phone:248-548-7707
Mailing Address - Fax:248-548-7736
Practice Address - Street 1:713 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1835
Practice Address - Country:US
Practice Address - Phone:248-548-7707
Practice Address - Fax:248-548-7736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF19360Medicare UPIN