Provider Demographics
NPI:1962892737
Name:ESSENTIAL DERMATOLOGY AND COSMETIC SURGERY PLLC
Entity type:Organization
Organization Name:ESSENTIAL DERMATOLOGY AND COSMETIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:806-241-4195
Mailing Address - Street 1:1105 SANTA FE DRIVE
Mailing Address - Street 2:STE 105
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5852
Mailing Address - Country:US
Mailing Address - Phone:806-241-4195
Mailing Address - Fax:
Practice Address - Street 1:1105 SANTA FE DRIVE
Practice Address - Street 2:STE 105
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5852
Practice Address - Country:US
Practice Address - Phone:806-241-4195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty