Provider Demographics
NPI:1952044968
Name:MODERN ESTHETICS & DERMATOLOGY,PLLC
Entity Type:Organization
Organization Name:MODERN ESTHETICS & DERMATOLOGY,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:701-201-0636
Mailing Address - Street 1:322 5TH ST E
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-1402
Mailing Address - Country:US
Mailing Address - Phone:701-201-0636
Mailing Address - Fax:
Practice Address - Street 1:514 THOMPSON ST STE 1
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-1238
Practice Address - Country:US
Practice Address - Phone:701-201-0636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty