Provider Demographics
NPI:1831964915
Name:MODERN DERMATOLOGY OF MASSACHUSETTS, PLLC
Entity type:Organization
Organization Name:MODERN DERMATOLOGY OF MASSACHUSETTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-974-3037
Mailing Address - Street 1:7 LAMBERT LN
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:RI
Mailing Address - Zip Code:02885-1639
Mailing Address - Country:US
Mailing Address - Phone:508-974-3037
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST STE 402
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2130
Practice Address - Country:US
Practice Address - Phone:508-974-3037
Practice Address - Fax:434-423-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-20
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty