Provider Demographics
NPI:1639398522
Name:REYES, OLGA L (DDS)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:L
Last Name:REYES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 E RIVERSIDE DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-6483
Mailing Address - Country:US
Mailing Address - Phone:909-923-7734
Mailing Address - Fax:909-923-7736
Practice Address - Street 1:1945 E RIVERSIDE DR
Practice Address - Street 2:SUITE 6
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-6483
Practice Address - Country:US
Practice Address - Phone:909-923-7734
Practice Address - Fax:909-923-7736
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD497921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9286001Medicaid