Healthcare Provider Details

I. General information

NPI: 1356725535
Provider Name (Legal Business Name): LONG DAO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10024 SE 240TH ST SUITE 220
KENT WA
98031-5124
US

IV. Provider business mailing address

10024 SE 240TH ST SUITE 220
KENT WA
98031-5124
US

V. Phone/Fax

Practice location:
  • Phone: 253-852-5440
  • Fax:
Mailing address:
  • Phone: 253-852-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008336
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number60636872
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: