Provider Demographics
NPI:1245051390
Name:MOSAIC DERMATOLOGY PLLC
Entity type:Organization
Organization Name:MOSAIC DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-415-8615
Mailing Address - Street 1:567 32ND AVE E STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8480
Mailing Address - Country:US
Mailing Address - Phone:701-941-3100
Mailing Address - Fax:701-941-3301
Practice Address - Street 1:567 32ND AVE E STE 100
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8480
Practice Address - Country:US
Practice Address - Phone:701-941-3100
Practice Address - Fax:701-941-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty