Provider Demographics
NPI:1972676021
Name:RHODE ISLAND DERMATOLOGY & COSMETIC CENTER LLC
Entity Type:Organization
Organization Name:RHODE ISLAND DERMATOLOGY & COSMETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:VIDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-475-5991
Mailing Address - Street 1:3 WAKE ROBIN RD
Mailing Address - Street 2:UNIT 5
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4208
Mailing Address - Country:US
Mailing Address - Phone:401-475-9140
Mailing Address - Fax:401-475-9143
Practice Address - Street 1:3 WAKE ROBIN RD
Practice Address - Street 2:UNIT 5
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4208
Practice Address - Country:US
Practice Address - Phone:401-475-9140
Practice Address - Fax:401-475-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI=========OtherTIN