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General NPI Number Information
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NPI Number | 1407144330
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Entity Type | Individual
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Provider Name | DWIGHT GREGORY OPTICIAN
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Gender | Male
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Dates
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Enumeration Date | 07/12/2011
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Last Update Date | 08/19/2011
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Provider Practice Location Address
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Address Line | 11940 FOOTHILL BLVD STE 107
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91739-9375
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Country | US
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Telephone | 909-944-1451
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Fax | 909-944-5174
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Provider Business Mailing Address
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Address Line | 720 S OLIVE ST
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City | ANAHEIM
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State | CA
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Zip | 92805-4741
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Country | US
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Telephone | 714-420-1841
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 6462
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 7602
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License Number State | CA
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