Provider Demographics
NPI:1770020471
Name:RESTORE SD PLASTIC SURGERY
Entity Type:Organization
Organization Name:RESTORE SD PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-444-7578
Mailing Address - Street 1:13056 SEAGROVE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3203
Mailing Address - Country:US
Mailing Address - Phone:858-444-7578
Mailing Address - Fax:
Practice Address - Street 1:8929 UNIVERSITY CENTER LN
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1006
Practice Address - Country:US
Practice Address - Phone:858-444-7578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA629402086S0122X
CAA671262086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty