Provider Demographics
NPI:1932360757
Name:ADVANCED DERMATOLOGY,P.C.
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-739-7546
Mailing Address - Street 1:PO BOX 76737
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30358-1737
Mailing Address - Country:US
Mailing Address - Phone:770-739-7546
Mailing Address - Fax:770-739-7920
Practice Address - Street 1:6043 PRESTLEY MILL RD
Practice Address - Street 2:SUITE#B
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2280
Practice Address - Country:US
Practice Address - Phone:770-739-7546
Practice Address - Fax:770-739-7920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037741174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID NUMBER