Provider Demographics
NPI:1821636564
Name:RADIANT DERMATOLOGY FALL CREEK PLLC
Entity Type:Organization
Organization Name:RADIANT DERMATOLOGY FALL CREEK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LIET
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-777-7559
Mailing Address - Street 1:9240 N SAM HOUSTON PKWY E
Mailing Address - Street 2:STE 201
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396
Mailing Address - Country:US
Mailing Address - Phone:832-777-7559
Mailing Address - Fax:832-777-7541
Practice Address - Street 1:9240 N SAM HOUSTON PKWY E
Practice Address - Street 2:STE 201
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396
Practice Address - Country:US
Practice Address - Phone:832-777-7559
Practice Address - Fax:832-777-7541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty