Provider Demographics
NPI:1568238111
Name:DENALI FACIAL PLASTIC SURGERY & ENT, LLC
Entity Type:Organization
Organization Name:DENALI FACIAL PLASTIC SURGERY & ENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:REID
Authorized Official - Last Name:MCILWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-987-4988
Mailing Address - Street 1:1108 7TH AVE APT 250
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 7TH AVE APT 250
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4774
Practice Address - Country:US
Practice Address - Phone:907-987-4988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty