Provider Demographics
NPI:1154117463
Name:PREMIER DERMATOLOGY SERVICES, PLLC
Entity type:Organization
Organization Name:PREMIER DERMATOLOGY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-876-8501
Mailing Address - Street 1:901 SE PLAZA AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-5473
Mailing Address - Country:US
Mailing Address - Phone:479-273-3376
Mailing Address - Fax:479-273-3468
Practice Address - Street 1:901 SE PLAZA AVE STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5473
Practice Address - Country:US
Practice Address - Phone:479-273-3376
Practice Address - Fax:479-273-3468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty