Provider Demographics
NPI:1043096365
Name:DERMATOLOGY AND PLASTIC SURGERY SPECIALISTS PLLC
Entity type:Organization
Organization Name:DERMATOLOGY AND PLASTIC SURGERY SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-930-6588
Mailing Address - Street 1:245 W STATE HIGHWAY 114 SUITE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-912-1200
Mailing Address - Fax:
Practice Address - Street 1:245 W STATE HIGHWAY 114 SUITE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-912-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOLOGY AND PLASTIC SURGERY SPECIALISTS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty