Provider Demographics
NPI:1952929424
Name:HASAN, AHMAD
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:HASAN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:AHMAD
Other - Middle Name:
Other - Last Name:HASAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:13726 LEGEND TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1104
Mailing Address - Country:US
Mailing Address - Phone:708-567-8610
Mailing Address - Fax:
Practice Address - Street 1:3320 CHICAGO RD
Practice Address - Street 2:
Practice Address - City:SOUTH CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-5423
Practice Address - Country:US
Practice Address - Phone:708-567-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0326061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice