Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN327 | WA |
NPI | 1376784934 |
---|---|
Provider Name | Phong Anh Vong |
First Address | Seattle, WA 98106-2876 |
Second Address | Seattle, WA 98106-2876 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2009 |
Last Update Date | 11/03/2009 |