Provider Demographics
NPI:1306317581
Name:DERMATOLOGY AND COSMETIC CENTER OF OKLAHOMA, P.L.L.C.
Entity type:Organization
Organization Name:DERMATOLOGY AND COSMETIC CENTER OF OKLAHOMA, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-701-9073
Mailing Address - Street 1:5355 RETREAT CIR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7627
Mailing Address - Country:US
Mailing Address - Phone:405-701-9073
Mailing Address - Fax:
Practice Address - Street 1:3580 RC LUTTRELL DR STE 102
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-9702
Practice Address - Country:US
Practice Address - Phone:405-701-9073
Practice Address - Fax:405-310-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty