Provider Demographics
NPI:1871633438
Name:BENGO, GLORIA D
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:D
Last Name:BENGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10923 VEACH ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6524
Mailing Address - Country:US
Mailing Address - Phone:909-801-8140
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1715 W REDLANDS BLVD
Practice Address - Street 2:SUITE #B
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8012
Practice Address - Country:US
Practice Address - Phone:909-801-8140
Practice Address - Fax:909-801-8148
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52344Medicaid