Healthcare Provider Details

I. General information

NPI: 1447123120
Provider Name (Legal Business Name): TESORO LUIS KOSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2025
Last Update Date: 09/27/2025
Certification Date: 09/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30818 PACIFIC HWY S
FEDERAL WAY WA
98003-4902
US

IV. Provider business mailing address

22611 112TH AVE SE
KENT WA
98031-2656
US

V. Phone/Fax

Practice location:
  • Phone: 253-217-6850
  • Fax: 253-839-1505
Mailing address:
  • Phone: 253-217-6850
  • Fax: 253-217-6850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number61459879
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: