Provider Demographics
NPI:1396338190
Name:ESSENTIAL DERMATOLOGY GROUP, PLLC
Entity type:Organization
Organization Name:ESSENTIAL DERMATOLOGY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:817-736-2912
Mailing Address - Street 1:1600 CENTRAL DR STE 158
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6000
Mailing Address - Country:US
Mailing Address - Phone:817-736-2912
Mailing Address - Fax:817-736-2912
Practice Address - Street 1:1600 CENTRAL DR STE 158
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6000
Practice Address - Country:US
Practice Address - Phone:817-736-2912
Practice Address - Fax:817-736-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty