Provider Demographics
NPI:1861738460
Name:RADIANT SKIN DERMATOLOGY AND LASER,PLLC
Entity type:Organization
Organization Name:RADIANT SKIN DERMATOLOGY AND LASER,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADEBOLA
Authorized Official - Middle Name:OLUFUNMI
Authorized Official - Last Name:DELE-MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-229-0007
Mailing Address - Street 1:234 CENTRAL PARK W
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6003
Mailing Address - Country:US
Mailing Address - Phone:212-229-0007
Mailing Address - Fax:212-202-6350
Practice Address - Street 1:207 W 115TH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2965
Practice Address - Country:US
Practice Address - Phone:212-229-0007
Practice Address - Fax:347-274-8349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256265207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty