Provider Demographics
NPI:1831228576
Name:ESSENCE DERMATOLOGY PLLC
Entity type:Organization
Organization Name:ESSENCE DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:OTOBIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:DIMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-848-2890
Mailing Address - Street 1:PO BOX 268945
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8945
Mailing Address - Country:US
Mailing Address - Phone:405-521-1969
Mailing Address - Fax:405-521-1979
Practice Address - Street 1:5005 N PENNSYLVANIA AVE STE 105
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8886
Practice Address - Country:US
Practice Address - Phone:405-848-2890
Practice Address - Fax:405-848-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI29165Medicare UPIN
OK500522191Medicare PIN