Provider Demographics
NPI:1861776791
Name:MAT-SU PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:MAT-SU PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-859-6261
Mailing Address - Street 1:2490 S WOODWORTH LOOP
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2490 S WOODWORTH LOOP
Practice Address - Street 2:SUITE 310
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7405
Practice Address - Country:US
Practice Address - Phone:907-746-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6242208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8928018Medicaid