Provider Demographics
NPI:1811478092
Name:DERMWELLESLEY LLC
Entity type:Organization
Organization Name:DERMWELLESLEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:857-317-2057
Mailing Address - Street 1:20 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-4103
Mailing Address - Country:US
Mailing Address - Phone:781-591-4234
Mailing Address - Fax:857-317-2811
Practice Address - Street 1:20 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-4103
Practice Address - Country:US
Practice Address - Phone:781-591-4234
Practice Address - Fax:781-369-9737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254256207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487882270OtherINDIVIDUAL NPI