Provider Demographics
NPI:1558851303
Name:EL HASSAN, HOUSSAM
Entity type:Individual
Prefix:
First Name:HOUSSAM
Middle Name:
Last Name:EL HASSAN
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 1:1 EXECUTIVE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH JUNCTION
Mailing Address - State:NJ
Mailing Address - Zip Code:08852-2446
Mailing Address - Country:US
Mailing Address - Phone:908-202-0323
Mailing Address - Fax:
Practice Address - Street 1:1 EXECUTIVE DR STE 103
Practice Address - Street 2:
Practice Address - City:MONMOUTH JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08852-2446
Practice Address - Country:US
Practice Address - Phone:908-202-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028885001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program