MEDICARE: LIBAN HASSAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	D15299	MN

General Provider Information

NPI Number	:	1215722442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBAN HASSAN

Provider Business Mailing Address
First Line	:	248 OAK DR
Second Line	:
City	:	EAGLE LAKE
State	:	MN
Zip	:	56024-3404
Country	:	US
Telephone Number	:	507-491-0668
Fax Number	:

Provider Business Practice Location Address
First Line	:	1290 SALEM RD SW # 10
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55902-4210
Country	:	US
Telephone Number	:	507-686-6968
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2025
Last Update Date	:	06/05/2025

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Directions to “ LIBAN HASSAN ” Practice Location

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