1275701419 NPI number — DEAN PLASTIC SURGERY ASSOCIATES, INC.

Table of content: (NPI 1275701419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275701419 NPI number — DEAN PLASTIC SURGERY ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEAN PLASTIC SURGERY ASSOCIATES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275701419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 N MAYFAIR RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-2252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-258-9511
Provider Business Mailing Address Fax Number:
414-607-3946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4832 LINCOLN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARINA DEL REY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90292-6917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-860-0646
Provider Business Practice Location Address Fax Number:
310-496-0252
Provider Enumeration Date:
02/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DEAN
Authorized Official First Name:
SHAY
Authorized Official Middle Name:
BYRON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-860-0646

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208200000X , with the licence number: A96010 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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