Provider Demographics
NPI:1972991503
Name:HAN, MIN SOO (DDS)
Entity Type:Individual
Prefix:
First Name:MIN SOO
Middle Name:
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 1:2057 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3548
Mailing Address - Country:US
Mailing Address - Phone:909-982-0188
Mailing Address - Fax:
Practice Address - Street 1:2057 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3548
Practice Address - Country:US
Practice Address - Phone:909-982-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64031122300000X
TX30498122300000X
ORD10176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist