Healthcare Provider Details

I. General information

NPI: 1689056038
Provider Name (Legal Business Name): GLENN ONG-VELOSO DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16098 KAMANA RD
APPLE VALLEY CA
92307-1335
US

IV. Provider business mailing address

16098 KAMANA RD
APPLE VALLEY CA
92307-1335
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-2620
  • Fax: 760-242-4700
Mailing address:
  • Phone: 760-242-2620
  • Fax: 760-242-4700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number44347
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN ONG-VELOSO
Title or Position: OWNER
Credential: DDS
Phone: 760-242-2620