Provider Demographics
NPI:1891879615
Name:ESTHETICS CENTER FOR DERMATOLOGY PA
Entity Type:Organization
Organization Name:ESTHETICS CENTER FOR DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-370-2700
Mailing Address - Street 1:353 CLEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2431
Mailing Address - Country:US
Mailing Address - Phone:704-370-2700
Mailing Address - Fax:704-370-2702
Practice Address - Street 1:353 CLEMENT AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2431
Practice Address - Country:US
Practice Address - Phone:704-370-2700
Practice Address - Fax:704-370-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127728174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty