Provider Demographics
NPI:1942961750
Name:ADVANCED DERM MASS, LLC
Entity Type:Organization
Organization Name:ADVANCED DERM MASS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-402-1000
Mailing Address - Street 1:526 MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3301
Mailing Address - Country:US
Mailing Address - Phone:978-371-7010
Mailing Address - Fax:
Practice Address - Street 1:802 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2708
Practice Address - Country:US
Practice Address - Phone:978-371-7010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DERMATOLOGY OF MELROSE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-04
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty