Healthcare Provider Details

I. General information

NPI: 1679973036
Provider Name (Legal Business Name): WENDY SUGIONO, DDS, MAGD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9482 BASELINE RD
ALTA LOMA CA
91701-5822
US

IV. Provider business mailing address

9482 BASELINE RD
ALTA LOMA CA
91701-5822
US

V. Phone/Fax

Practice location:
  • Phone: 909-980-1411
  • Fax:
Mailing address:
  • Phone: 909-980-1411
  • Fax: 909-980-7061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62552
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27931
License Number StateCA

VIII. Authorized Official

Name: DR. WENDY SUGIONO
Title or Position: CEO
Credential: DDS
Phone: 909-980-1411