MEDICARE: IRENE M JUSTIN DDS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	51084	CA

General Provider Information

NPI Number	:	1437576360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRENE M JUSTIN DDS INC

Provider Business Mailing Address
First Line	:	2413 S GROVE AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-6225
Country	:	US
Telephone Number	:	909-947-9700
Fax Number	:	909-947-7611

Provider Business Practice Location Address
First Line	:	2413 S GROVE AVE
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-6225
Country	:	US
Telephone Number	:	909-947-9700
Fax Number	:	909-947-7611

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRENE M JUSTIN
Credential	:	DDS
Telephone Number	:	909-947-9700

Provider Enumeration Date	:	03/28/2014
Last Update Date	:	03/28/2014

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