Organization · NPI-2

Form MD Plastic Surgery

Otolaryngology, Otolaryngology/Facial Plastic Surgery · Mission Viejo, CA

NPI number1164053104
StatusActive
Last updated in NPPESApr 26, 2023

Details

NPI
1164053104
Entity type
Organization (NPI-2)
Legal business name
Form MD Plastic Surgery
Organization subpart
No
Enumeration date
Jan 29, 2020
Certification date
Apr 26, 2023
Last updated
Apr 26, 2023

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
207YX0905X Otolaryngology, Otolaryngology/Facial Plastic Surgery––Yes
208600000X Surgery––
261QM2500X Clinic/Center, Medical Specialty––

Practice location

26691 Plaza Ste 200
Mission Viejo, CA 92691-8582

Phone 949-998-2020

Mailing address

26691 Plaza Ste 200
Mission Viejo, CA 92691-8582

Phone 949-998-2020 · Fax 949-998-2021

Authorized official

Taylor R Pollei
Ceo/Provider
9499982020

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