Provider Demographics
NPI:1245447218
Name:BEAUTY THRU HEALTH DERMATOLOGY, P.C.
Entity type:Organization
Organization Name:BEAUTY THRU HEALTH DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:LAPIERCE
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:405-278-7911
Mailing Address - Street 1:PO BOX 2074
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-2074
Mailing Address - Country:US
Mailing Address - Phone:405-278-7911
Mailing Address - Fax:405-278-7925
Practice Address - Street 1:1211 N SHARTEL AVE STE 407
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2425
Practice Address - Country:US
Practice Address - Phone:405-278-7911
Practice Address - Fax:405-278-7925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522112OtherMEDICARE PTAN
OK300522112OtherMEDICARE PTAN
OKB69256Medicare UPIN
OK200067530AOtherMEDICAID GROUP #
OK300522112OtherMEDICARE PTAN
OK=========OtherFEDERAL TAX ID
OK243432400OtherMEDICARE PROVIDER ID
OK100254210BMedicaid