Provider Demographics
NPI:1891986204
Name:ALAMITOS DERMATOLOGICAL MEDICAL CLINIC A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:ALAMITOS DERMATOLOGICAL MEDICAL CLINIC A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:T
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-619-8440
Mailing Address - Street 1:12721 NEWPORT AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-8030
Mailing Address - Country:US
Mailing Address - Phone:714-838-5680
Mailing Address - Fax:714-544-1321
Practice Address - Street 1:12721 NEWPORT AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-8030
Practice Address - Country:US
Practice Address - Phone:714-838-5680
Practice Address - Fax:714-544-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1155EMedicare UPIN