Healthcare Provider Details

I. General information

NPI: 1164146783
Provider Name (Legal Business Name): HASAN MOHAMMED AL-BALWAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15159 E COLFAX AVE UNIT B
AURORA CO
80011-5707
US

IV. Provider business mailing address

2100 N URSULA ST UNIT 425
AURORA CO
80045-7412
US

V. Phone/Fax

Practice location:
  • Phone: 303-341-5437
  • Fax:
Mailing address:
  • Phone: 720-277-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00205361
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: