Organization
ADVANCED DERMATOLOGY CARE MEDICAL COSMETIC AND SURGERY PA
Active
Other names
Advanced Dermatology Care
Organization subpart
No
Provider details
NPI number
Authorized official
OLAF JONATHAN RUSTAD MD (DERMATOLOGIST PRESIDENT)
(651) 484-2724
Entity
Organization
Contact information
Practice address
14130 60TH ST N, STILLWATER, MN 55082-6354
(651) 484-2724
Mailing address
4480 CENTERVILLE RD, WHITE BEARLAKE, MN 55127
(651) 484-2724
(651) 484-2724
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
1376
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
070000195
PTAN
MN
01
—
C01783
GROUP LEGACY
MN
Enumeration date
07/31/2008
Last updated
03/11/2024
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