Provider Demographics
NPI:1871352963
Name:HAN, SUNG PHILL
Entity type:Individual
Prefix:
First Name:SUNG PHILL
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 1:25183 PROSPECT AVE APT D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2904
Mailing Address - Country:US
Mailing Address - Phone:424-382-8542
Mailing Address - Fax:
Practice Address - Street 1:61325 29 PALMS HWY STE A
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-1912
Practice Address - Country:US
Practice Address - Phone:760-366-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1099081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice