Provider Demographics
NPI:1588897102
Name:PINNACLE DERMATOLOGY
Entity type:Organization
Organization Name:PINNACLE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEETTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD FAAD FRCPC
Authorized Official - Phone:425-999-2628
Mailing Address - Street 1:PO BOX 3418
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98083-3418
Mailing Address - Country:US
Mailing Address - Phone:425-999-2628
Mailing Address - Fax:253-559-9020
Practice Address - Street 1:1515 116TH AVE NE
Practice Address - Street 2:STE 307
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3811
Practice Address - Country:US
Practice Address - Phone:425-999-2628
Practice Address - Fax:253-559-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-30
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD025209MD00035417207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty