Healthcare Provider Details

I. General information

NPI: 1265797997
Provider Name (Legal Business Name): DASHAINI VICTORIA RETNASOTHIE OD, MSC, BSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5460 E LA PALMA AVE
ANAHEIM CA
92807
US

IV. Provider business mailing address

5460 E LA PALMA AVE
ANAHEIM CA
92807-2023
US

V. Phone/Fax

Practice location:
  • Phone: 714-463-7500
  • Fax:
Mailing address:
  • Phone: 714-463-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8326T
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number14413
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number14413
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: