Provider Demographics
NPI:1316797640
Name:CLEAR CHOICE DERMATOLOGY
Entity type:Organization
Organization Name:CLEAR CHOICE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BLATTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-228-1967
Mailing Address - Street 1:PO BOX 2430
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8022
Mailing Address - Country:US
Mailing Address - Phone:541-316-6575
Mailing Address - Fax:541-210-8913
Practice Address - Street 1:1610 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2821
Practice Address - Country:US
Practice Address - Phone:541-316-6575
Practice Address - Fax:541-210-8913
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEAR CHOICE DERMATOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty