Provider Demographics
NPI:1053005603
Name:HAN, HAE JIN
Entity type:Individual
Prefix:
First Name:HAE JIN
Middle Name:
Last Name:HAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 S VAL VISTA DR APT 260
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6180
Mailing Address - Country:US
Mailing Address - Phone:415-606-2258
Mailing Address - Fax:
Practice Address - Street 1:1439 S VAL VISTA DR APT 260
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6180
Practice Address - Country:US
Practice Address - Phone:415-606-2258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist