Basic Information
Provider Information | |||||||||
NPI: | 1265033138 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKE LOVELAND DERMATOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7643 | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805370643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706632742 | ||||||||
FaxNumber: | 9703422093 | ||||||||
Practice Location | |||||||||
Address1: | 555 PROSPECT AVE | ||||||||
Address2: |   | ||||||||
City: | ESTES PARK | ||||||||
State: | CO | ||||||||
PostalCode: | 805176312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706673119 | ||||||||
FaxNumber: | 9706690159 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2020 | ||||||||
LastUpdateDate: | 01/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOTT | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3035697700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: | 01/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207ND0900X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.