Provider Demographics
NPI:1245438365
Name:WONG, DENNIS (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7608
Mailing Address - Country:US
Mailing Address - Phone:909-421-2020
Mailing Address - Fax:909-990-1560
Practice Address - Street 1:1366 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376
Practice Address - Country:US
Practice Address - Phone:909-421-2020
Practice Address - Fax:909-285-9586
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245438365Medicaid