Provider Demographics
NPI:1730506064
Name:GREEN LAKE FACIAL SURGERY PLLC
Entity type:Organization
Organization Name:GREEN LAKE FACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:EPSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:120-696-3906
Mailing Address - Street 1:7900 E GREEN LAKE DR N
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-4800
Mailing Address - Country:US
Mailing Address - Phone:206-693-3906
Mailing Address - Fax:
Practice Address - Street 1:7900 E GREEN LAKE DR N
Practice Address - Street 2:SUITE 302
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-4800
Practice Address - Country:US
Practice Address - Phone:206-693-3906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60277222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental