Healthcare Provider Details

I. General information

NPI: 1265927578
Provider Name (Legal Business Name): MOENA DEAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 SANTA FE DR STE 104
ENCINITAS CA
92024-5139
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 800-898-2020
  • Fax:
Mailing address:
  • Phone: 951-260-3573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT33955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: