Provider Demographics
NPI:1699836908
Name:TRIAD DERMATOLOGY PA
Entity type:Organization
Organization Name:TRIAD DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-768-2180
Mailing Address - Street 1:725 HIGHLAND OAKS DRIVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-768-2180
Mailing Address - Fax:336-768-8031
Practice Address - Street 1:725 HIGHLAND OAKS DRIVE
Practice Address - Street 2:SUITE 106
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-2180
Practice Address - Fax:336-768-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28663207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2329213Medicare ID - Type Unspecified
C81931Medicare UPIN