Provider Demographics
NPI:1346389178
Name:ADVANCED DERMATOLOGY CENTER, PC
Entity type:Organization
Organization Name:ADVANCED DERMATOLOGY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:ODAY
Authorized Official - Last Name:BODDICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-343-8000
Mailing Address - Street 1:PO BOX 3468
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-3468
Mailing Address - Country:US
Mailing Address - Phone:605-343-8000
Mailing Address - Fax:605-343-8262
Practice Address - Street 1:710 SAINT ANNE STREET
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-343-8000
Practice Address - Fax:605-343-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
SD0329207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0006246OtherBLUE CROSS
SC0006246OtherBLUE CROSS