Provider Demographics
NPI:1912464157
Name:LUCENT DERMATOLOGY AND SKIN SURGERY CENTER CORP
Entity type:Organization
Organization Name:LUCENT DERMATOLOGY AND SKIN SURGERY CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-612-6412
Mailing Address - Street 1:7550 LUCERNE DR STE 405
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-6503
Mailing Address - Country:US
Mailing Address - Phone:440-234-8833
Mailing Address - Fax:
Practice Address - Street 1:2000 AUBURN DR STE 120
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4328
Practice Address - Country:US
Practice Address - Phone:440-234-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty