Basic Information
Provider Information
NPI: 1407205818
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HAN
FirstName: AILEEN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 18 JACKSON ST
Address2:  
City: PELLA
State: IA
PostalCode: 502191398
CountryCode: US
TelephoneNumber: 5153261000
FaxNumber:  
Practice Location
Address1: 107 COMMERCIAL ST
Address2:  
City: MASHPEE
State: MA
PostalCode: 026496507
CountryCode: US
TelephoneNumber: 5084777090
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/07/2016
LastUpdateDate: 06/07/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XDN1857179MAY Dental ProvidersDentist 

No ID Information.


Home