Provider Demographics
NPI:1922060649
Name:DAVIE DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:DAVIE DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-940-2407
Mailing Address - Street 1:108 DORNACH WAY
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7305
Mailing Address - Country:US
Mailing Address - Phone:336-940-2407
Mailing Address - Fax:336-940-2409
Practice Address - Street 1:108 DORNACH WAY
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7305
Practice Address - Country:US
Practice Address - Phone:336-940-2407
Practice Address - Fax:336-940-2409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890108VMedicaid
NC890108VMedicaid