Provider Demographics
NPI:1669059713
Name:SALT LAKE DERMATOLOGY AND AESTHETICS PC
Entity type:Organization
Organization Name:SALT LAKE DERMATOLOGY AND AESTHETICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:SOTIRIOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-521-5630
Mailing Address - Street 1:250 E 300 S STE 120
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2418
Mailing Address - Country:US
Mailing Address - Phone:801-521-5630
Mailing Address - Fax:801-596-9780
Practice Address - Street 1:250 E 300 S STE 120
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2418
Practice Address - Country:US
Practice Address - Phone:801-521-5630
Practice Address - Fax:801-596-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-25
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty