Provider Demographics
NPI:1962544767
Name:BURLINGTON DERMATOLOGY CENTER, INC.
Entity type:Organization
Organization Name:BURLINGTON DERMATOLOGY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-226-9393
Mailing Address - Street 1:1522 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2871
Mailing Address - Country:US
Mailing Address - Phone:336-226-9393
Mailing Address - Fax:336-227-0496
Practice Address - Street 1:1522 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2871
Practice Address - Country:US
Practice Address - Phone:336-226-9393
Practice Address - Fax:336-227-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13641174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901143Medicaid
NC8941461Medicaid
NC8901143Medicaid
NC8941461Medicaid