Provider Demographics
NPI:1184084055
Name:HASSAN, JOSHUA (DMD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:HASSAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 W JARVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1112
Mailing Address - Country:US
Mailing Address - Phone:908-812-2220
Mailing Address - Fax:
Practice Address - Street 1:2100 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-1641
Practice Address - Country:US
Practice Address - Phone:908-812-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.020434122300000X
IL019.031082122300000X
WI1001750-151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentist