Provider Demographics
NPI:1316720162
Name:FAMILY DERMATOLOGY PLLC
Entity type:Organization
Organization Name:FAMILY DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:253-948-8165
Mailing Address - Street 1:1104 ALLENWHITE DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9402
Mailing Address - Country:US
Mailing Address - Phone:253-948-8165
Mailing Address - Fax:
Practice Address - Street 1:2835 FORT MISSOULA RD STE 302
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7424
Practice Address - Country:US
Practice Address - Phone:406-721-3497
Practice Address - Fax:406-721-3487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-16
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty