Provider Demographics
NPI:1184299034
Name:GLASS DERMATOLOGY PLLC
Entity type:Organization
Organization Name:GLASS DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:910-990-7722
Mailing Address - Street 1:412 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2806
Mailing Address - Country:US
Mailing Address - Phone:910-490-1240
Mailing Address - Fax:910-490-1260
Practice Address - Street 1:412 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2806
Practice Address - Country:US
Practice Address - Phone:910-490-1240
Practice Address - Fax:910-490-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC202101095OtherNC MEDICAL LICENSE