Provider Demographics
NPI:1194479972
Name:DOCKSIDE DERMATOLOGY LLC
Entity type:Organization
Organization Name:DOCKSIDE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-533-4200
Mailing Address - Street 1:8601 VETERANS HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1566
Mailing Address - Country:US
Mailing Address - Phone:410-934-5400
Mailing Address - Fax:410-934-0141
Practice Address - Street 1:8601 VETERANS HWY STE 201
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1566
Practice Address - Country:US
Practice Address - Phone:410-934-5400
Practice Address - Fax:410-934-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2023-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty