Healthcare Provider Details

I. General information

NPI: 1801070032
Provider Name (Legal Business Name): DYNASTY OPTOMETRIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18371 PIONEER BLVD.
ARTESIA CA
90701-5532
US

IV. Provider business mailing address

18371 PIONEER BLVD.
ARTESIA CA
90701-5532
US

V. Phone/Fax

Practice location:
  • Phone: 562-865-4190
  • Fax: 562-865-3280
Mailing address:
  • Phone: 562-865-4190
  • Fax: 562-865-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT10361TPL
License Number StateCA

VIII. Authorized Official

Name: DR. CHENG-HONG JOHNSON LEE
Title or Position: OWNER / PRESIDENT
Credential: O.D.
Phone: 562-865-4190