Provider Demographics
NPI:1902146954
Name:HASAN, ISHMAEL (DDS)
Entity Type:Individual
Prefix:
First Name:ISHMAEL
Middle Name:
Last Name:HASAN
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:PO BOX 58312
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98138-1312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:907 FRONTIER CIR E STE 100
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-2423
Practice Address - Country:US
Practice Address - Phone:425-697-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 0583251223G0001X
WADE608567831223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice