Healthcare Provider Details

I. General information

NPI: 1942358965
Provider Name (Legal Business Name): SHAY BYRON DEAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4832 LINCOLN BLVD
MARINA DEL REY CA
90292
US

IV. Provider business mailing address

2200 NORTH MAYFAIR ROAD SUITE 200
WAUWATOSA WI
53226-2252
US

V. Phone/Fax

Practice location:
  • Phone: 310-482-6910
  • Fax: 310-496-0252
Mailing address:
  • Phone: 414-258-9511
  • Fax: 414-607-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA96010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: