Provider Demographics
NPI:1215963574
Name:BOSTON DERMATOLOGY AND LASER CENTER, LLC
Entity type:Organization
Organization Name:BOSTON DERMATOLOGY AND LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-371-7010
Mailing Address - Street 1:30 LANCASTER ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-1704
Mailing Address - Country:US
Mailing Address - Phone:617-722-4100
Mailing Address - Fax:617-227-1134
Practice Address - Street 1:30 LANCASTER STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2517
Practice Address - Country:US
Practice Address - Phone:617-722-4100
Practice Address - Fax:617-227-1134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty