Healthcare Provider Details

I. General information

NPI: 1841608197
Provider Name (Legal Business Name): HANI AHDAB DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 04/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 WINTHROP AVE
LAFAYETTE IN
47909-2420
US

IV. Provider business mailing address

1209 WINTHROP AVE
LAFAYETTE IN
47909-2420
US

V. Phone/Fax

Practice location:
  • Phone: 765-477-7722
  • Fax:
Mailing address:
  • Phone: 765-477-7722
  • Fax: 765-477-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12012631A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: