Provider Demographics
NPI:1710091491
Name:DANG, SALLY H (OD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:H
Last Name:DANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12302 GARDEN GROVE BLVD
Mailing Address - Street 2:STE 6
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843
Mailing Address - Country:US
Mailing Address - Phone:714-590-2020
Mailing Address - Fax:714-590-2044
Practice Address - Street 1:12302 GARDEN GROVE BLVD
Practice Address - Street 2:STE 6
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843
Practice Address - Country:US
Practice Address - Phone:714-590-2020
Practice Address - Fax:714-590-2044
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11249T152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0112490Medicaid
U79302Medicare UPIN
CASD0112490Medicaid