Healthcare Provider Details

I. General information

NPI: 1376784934
Provider Name (Legal Business Name): PHONG ANH VONG L.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9670 14TH AVE SW UNIT AB
SEATTLE WA
98106-2876
US

IV. Provider business mailing address

9670 14TH AVE SW UNIT AB
SEATTLE WA
98106-2876
US

V. Phone/Fax

Practice location:
  • Phone: 206-762-7222
  • Fax: 206-762-7783
Mailing address:
  • Phone: 206-762-7222
  • Fax: 206-762-7783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDN327
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: