Provider Demographics
NPI:1689900870
Name:IRENE M JUSTIN WILDWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:IRENE M JUSTIN WILDWOOD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-536-8419
Mailing Address - Street 1:2413 S GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-6225
Mailing Address - Country:US
Mailing Address - Phone:909-947-9700
Mailing Address - Fax:
Practice Address - Street 1:3972 N WATERMAN AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-1767
Practice Address - Country:US
Practice Address - Phone:909-947-9700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty