Provider Demographics
NPI:1710398953
Name:SUNDINE CENTER FOR FACIAL AESTHETICS AND PLASTIC SURGERY INC
Entity Type:Organization
Organization Name:SUNDINE CENTER FOR FACIAL AESTHETICS AND PLASTIC SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SUNDINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-706-3100
Mailing Address - Street 1:PO BOX 54370
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-4370
Mailing Address - Country:US
Mailing Address - Phone:949-706-3100
Mailing Address - Fax:949-706-3265
Practice Address - Street 1:1640 NEWPORT BLVD
Practice Address - Street 2:SUITE 450
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-706-3100
Practice Address - Fax:949-706-3265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66233208200000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF12019Medicare UPIN