Healthcare Provider Details

I. General information

NPI: 1457008435
Provider Name (Legal Business Name): GREEN LAKE ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15823 WESTMINSTER WAY N
SHORELINE WA
98133
US

IV. Provider business mailing address

7900 E GREEN LAKE DR N SUITE 302
SEATTLE WA
98103
US

V. Phone/Fax

Practice location:
  • Phone: 206-848-5788
  • Fax: 206-734-3747
Mailing address:
  • Phone: 360-391-7872
  • Fax: 206-734-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW SHANE EPSTEIN
Title or Position: OWNER/PROVIDER
Credential:
Phone: 206-641-7212