Provider Demographics
NPI:1740665165
Name:HAN, HEEJO
Entity type:Individual
Prefix:
First Name:HEEJO
Middle Name:
Last Name:HAN
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 1:530 VETERAN AVE APT 215A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-8001
Mailing Address - Country:US
Mailing Address - Phone:703-901-5931
Mailing Address - Fax:
Practice Address - Street 1:3700 WILSHIRE BLVD STE 780
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3001
Practice Address - Country:US
Practice Address - Phone:213-380-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA648321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice