Provider Demographics
NPI:1871697136
Name:ACCREDITED DERMATOLOGY MEDICAL CLINIC INC
Entity type:Organization
Organization Name:ACCREDITED DERMATOLOGY MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-525-3500
Mailing Address - Street 1:PO BOX 5859
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838
Mailing Address - Country:US
Mailing Address - Phone:714-525-3500
Mailing Address - Fax:714-525-3588
Practice Address - Street 1:301 W BASTANCHURY ROAD
Practice Address - Street 2:SUITE 245
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-525-3500
Practice Address - Fax:714-525-3588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13925Medicare ID - Type Unspecified