Provider Demographics
NPI:1144470808
Name:PRESTON RIDGE DERMATOLOGY, PC
Entity type:Organization
Organization Name:PRESTON RIDGE DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-475-6222
Mailing Address - Street 1:3155 N POINT PKWY
Mailing Address - Street 2:BLDG E STE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5494
Mailing Address - Country:US
Mailing Address - Phone:770-475-6222
Mailing Address - Fax:770-667-9522
Practice Address - Street 1:3155 N POINT PKWY
Practice Address - Street 2:BLDG E STE 100
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-5494
Practice Address - Country:US
Practice Address - Phone:770-475-6222
Practice Address - Fax:770-667-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027412207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty