Provider Demographics
NPI:1639235245
Name:HAN, EDISON S (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDISON
Middle Name:S
Last Name:HAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-2008
Mailing Address - Country:US
Mailing Address - Phone:626-339-9085
Mailing Address - Fax:
Practice Address - Street 1:153 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2008
Practice Address - Country:US
Practice Address - Phone:213-393-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA486081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD48608OtherRENDERING PROVIDER