Provider Demographics
NPI:1942496880
Name:ADVANCED DERMATOLOGY AND LASER CENTER P.A.
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY AND LASER CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-295-3376
Mailing Address - Street 1:107 CLAIR DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-7771
Mailing Address - Country:US
Mailing Address - Phone:864-295-3376
Mailing Address - Fax:864-295-9117
Practice Address - Street 1:107 CLAIR DR
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-7771
Practice Address - Country:US
Practice Address - Phone:864-295-3376
Practice Address - Fax:864-295-9117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13943207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC139433Medicaid
SC1457466971OtherNPI INDIVIDUAL
SC=========OtherTAX ID
SC1457466971OtherNPI INDIVIDUAL