Provider Demographics
NPI:1811874290
Name:DYNASTY DIAGNOSTICS
Entity type:Organization
Organization Name:DYNASTY DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECHNICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AHSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASEER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CLS
Authorized Official - Phone:714-493-1224
Mailing Address - Street 1:1718 COLORADO BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1338
Mailing Address - Country:US
Mailing Address - Phone:747-758-9797
Mailing Address - Fax:
Practice Address - Street 1:1718 COLORADO BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1338
Practice Address - Country:US
Practice Address - Phone:747-758-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2326157OtherCLIA