Basic Information
| Provider Information | |||||||||
| NPI: | 1104830918 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HANA DENTAL NY P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7523 FORT HAMILTON PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112282305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182384133 | ||||||||
| FaxNumber: | 7182389843 | ||||||||
| Practice Location | |||||||||
| Address1: | 7523 FORT HAMILTON PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112282305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182384133 | ||||||||
| FaxNumber: | 7182389843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KANG | ||||||||
| AuthorizedOfficialFirstName: | HAN | ||||||||
| AuthorizedOfficialMiddleName: | JONG | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7182384133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 048768 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02064120 | 05 | NY | MEDICAID |