Provider Demographics
NPI:1457008435
Name:GREEN LAKE ORAL & FACIAL SURGERY
Entity Type:Organization
Organization Name:GREEN LAKE ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
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:
Authorized Official - Phone:206-641-7212
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
Mailing Address - Country:US
Mailing Address - Phone:360-391-7872
Mailing Address - Fax:206-734-3211
Practice Address - Street 1:15823 WESTMINSTER WAY N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133
Practice Address - Country:US
Practice Address - Phone:206-848-5788
Practice Address - Fax:206-734-3747
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREEN LAKE ORAL & FACIAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty