Organization
ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Active
Parent organization
ADVANCED DERMATOLOGY CARE MEDICAL AND SURGICAL DERMATOLOGY PA
Other names
Advanced Dermatology Care
Organization subpart
Yes
Provider details
NPI number
Legal business name
ADVANCED DERMATOLOGY CARE MEDICAL AND SURGICAL DERMATOLOGY PA
Authorized official
MR. OLAF J RUSTAD (OWNER)
(651) 484-2724
Entity
Organization
Contact information
Practice address
4480 CENTERVILLE RD, WHITE BEAR LAKE, MN 55127-3674
(651) 484-2724
(651) 484-2723
Mailing address
4480 CENTERVILLE RD, WHITE BEAR LAKE, MN 55127-3674
(651) 484-2724
(651) 484-2723
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C01783
PTAN
MN
Enumeration date
09/26/2006
Last updated
11/16/2018
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