Healthcare Provider Details

I. General information

NPI: 1386638096
Provider Name (Legal Business Name): JONATHAN LEE HAUN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 M ST SE BLDG #166, BRANCH DENTAL CLINIC, WNY
WASHINGTON DC
20374-0001
US

IV. Provider business mailing address

238 WILSON ST
BALTIMORE MD
21217-4313
US

V. Phone/Fax

Practice location:
  • Phone: 202-433-2480
  • Fax:
Mailing address:
  • Phone: 571-330-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD6592
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: