Organization
PINE BELT DERMATOLOGY AND SKIN CANCER CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. JOY LYNN MOORE (OFFICE MANAGER)
(513) 267-3658
Entity
Organization
Contact information
Practice address
201 S MAIN ST, PETAL, MS 39465-2362
(513) 267-3658
Mailing address
201 S MAIN ST, PETAL, MS 39465-2362
(513) 267-3658
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
21178
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09537875
—
MS
Enumeration date
10/20/2014
Last updated
10/20/2014
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