Provider Demographics
NPI:1063084465
Name:HASAN, MASSARA
Entity type:Individual
Prefix:
First Name:MASSARA
Middle Name:
Last Name:HASAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 STATION BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4047
Mailing Address - Country:US
Mailing Address - Phone:630-492-3894
Mailing Address - Fax:
Practice Address - Street 1:5220 CENTRAL AVE NE STE 240
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-1823
Practice Address - Country:US
Practice Address - Phone:763-275-1319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033236122300000X
MND14681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist