Provider Demographics
NPI:1124166400
Name:DERMATOLOGY & LASER CLINIC, INC.
Entity type:Organization
Organization Name:DERMATOLOGY & LASER CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-631-0300
Mailing Address - Street 1:401 OLD NEWPORT BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4269
Mailing Address - Country:US
Mailing Address - Phone:949-631-0300
Mailing Address - Fax:949-631-0302
Practice Address - Street 1:401 OLD NEWPORT BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4269
Practice Address - Country:US
Practice Address - Phone:949-631-0300
Practice Address - Fax:949-631-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69586207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty