Provider Demographics
NPI:1831534742
Name:PACIFIC COAST CRANIOFACIAL AND PEDIATRIC PLASTIC SURGERY INC.
Entity type:Organization
Organization Name:PACIFIC COAST CRANIOFACIAL AND PEDIATRIC PLASTIC SURGERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDEN
Authorized Official - Prefix:
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 1:1640 NEWPORT BOULEVARD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-7737
Mailing Address - Country:US
Mailing Address - Phone:949-706-3100
Mailing Address - Fax:949-706-3265
Practice Address - Street 1:1640 NEWPORT BOULEVARD
Practice Address - Street 2:SUITE 450
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-7737
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:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty