Provider Demographics
NPI:1538761655
Name:BOLD CITY DERMATOLOGY LLC
Entity type:Organization
Organization Name:BOLD CITY DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BISHR
Authorized Official - Middle Name:
Authorized Official - Last Name:AL DABAGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-230-1302
Mailing Address - Street 1:316 PASEO REYES DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8464
Mailing Address - Country:US
Mailing Address - Phone:904-544-5800
Mailing Address - Fax:
Practice Address - Street 1:316 PASEO REYES DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8464
Practice Address - Country:US
Practice Address - Phone:904-544-5800
Practice Address - Fax:904-544-5800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-13
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty