Provider Demographics
NPI:1386481109
Name:DISTINCTIVE DERMATOLOGY PLLC
Entity type:Organization
Organization Name:DISTINCTIVE DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:ATWATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-239-0126
Mailing Address - Street 1:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-0064
Mailing Address - Country:US
Mailing Address - Phone:703-570-1192
Mailing Address - Fax:
Practice Address - Street 1:8603 WESTWOOD CENTER DR STE 320
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2230
Practice Address - Country:US
Practice Address - Phone:703-570-1192
Practice Address - Fax:703-382-6654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty