Provider Demographics
NPI:1639879364
Name:FAKHRULDDIN, HASSNEN
Entity Type:Individual
Prefix:
First Name:HASSNEN
Middle Name:
Last Name:FAKHRULDDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10510 W ALIANA TRACE DR APT 101
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1138
Mailing Address - Country:US
Mailing Address - Phone:832-778-7312
Mailing Address - Fax:
Practice Address - Street 1:6407 HILLCROFT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-3101
Practice Address - Country:US
Practice Address - Phone:832-778-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist