Provider Demographics
NPI:1730930447
Name:NORTHSHORE STAR FACIAL PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:NORTHSHORE STAR FACIAL PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDEL-TATCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-898-5336
Mailing Address - Street 1:700 OSTERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4375
Mailing Address - Country:US
Mailing Address - Phone:224-513-6500
Mailing Address - Fax:
Practice Address - Street 1:700 OSTERMAN AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4375
Practice Address - Country:US
Practice Address - Phone:224-513-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty