Provider Demographics
NPI:1336281112
Name:GAEDIG, DENNIS LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:LEE
Last Name:GAEDIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15589 FICUS ST
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-4251
Mailing Address - Country:US
Mailing Address - Phone:909-597-4136
Mailing Address - Fax:909-484-2060
Practice Address - Street 1:1 MILLS CIR
Practice Address - Street 2:1016
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5207
Practice Address - Country:US
Practice Address - Phone:909-481-1083
Practice Address - Fax:909-484-2060
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6661T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist