Provider Demographics
NPI:1669442000
Name:LE, DAI DAN (OD)
Entity type:Individual
Prefix:MRS
First Name:DAI
Middle Name:DAN
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DAI AMIE
Other - Middle Name:
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:SUITE 170-452
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-0806
Mailing Address - Country:US
Mailing Address - Phone:703-622-7233
Mailing Address - Fax:916-788-4536
Practice Address - Street 1:11011 LEE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5002
Practice Address - Country:US
Practice Address - Phone:703-691-7584
Practice Address - Fax:703-691-9770
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA06018001141152W00000X
VA0618001141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V08415Medicare UPIN
VA492095Medicare ID - Type Unspecified