Provider Demographics
NPI:1255645776
Name:MCLEAN DERMATOLOGY AND SKINCARE CENTER
Entity type:Organization
Organization Name:MCLEAN DERMATOLOGY AND SKINCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:TALAKOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-356-5111
Mailing Address - Street 1:PO BOX 9143
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-0143
Mailing Address - Country:US
Mailing Address - Phone:703-356-5111
Mailing Address - Fax:703-388-0873
Practice Address - Street 1:6849 OLD DOMINION DR
Practice Address - Street 2:SUITE 340
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3724
Practice Address - Country:US
Practice Address - Phone:703-356-5111
Practice Address - Fax:703-388-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012445533261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty