Basic Information
| Provider Information | |||||||||
| NPI: | 1477640902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY AND SKIN SURGERY CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 CELEBRATION PL | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CELEBRATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347475433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075661616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 CELEBRATION PL | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CELEBRATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347475433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075661616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOODLESS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4075661616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME0058612 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.