MEDICARE: WENDY SUGIONO, DDS, MAGD, 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	62552	CA
2	1223G0001X	General Practice Dentistry	27931	CA

General Provider Information

NPI Number	:	1679973036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WENDY SUGIONO, DDS, MAGD, INC.

Provider Business Mailing Address
First Line	:	9482 BASELINE RD
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-5822
Country	:	US
Telephone Number	:	909-980-1411
Fax Number	:	909-980-7061

Provider Business Practice Location Address
First Line	:	9482 BASELINE RD
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-5822
Country	:	US
Telephone Number	:	909-980-1411
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. WENDY SUGIONO
Credential	:	DDS
Telephone Number	:	909-980-1411

Provider Enumeration Date	:	09/03/2014
Last Update Date	:	09/03/2014

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