Organization · NPI-2

Form MD 360

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

NPI number1700557899
StatusActive
Last updated in NPPESApr 26, 2023

Details

NPI
1700557899
Entity type
Organization (NPI-2)
Legal business name
Form MD 360
Organization subpart
No
Enumeration date
Sep 28, 2021
Certification date
Apr 26, 2023
Last updated
Apr 26, 2023

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
207YX0905X Otolaryngology, Otolaryngology/Facial Plastic Surgery––Yes
2086S0122X Surgery, Plastic and Reconstructive Surgery––
207YS0123X Otolaryngology, Facial Plastic Surgery––

Practice location

26691 Plaza Ste 200
Mission Viejo, CA 92691-8582

Phone 949-438-3644 · Fax 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 Pollei
Ceo / Owner
9499982020

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