Healthcare Provider Details

I. General information

NPI: 1780173955
Provider Name (Legal Business Name): SANDY JAEHYUN HA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 OLD MARLTON PIKE W STE C
MARLTON NJ
08053-2089
US

IV. Provider business mailing address

475 OLD MARLTON PIKE W STE C
MARLTON NJ
08053-2089
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-0202
  • Fax:
Mailing address:
  • Phone: 856-983-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number22DI03092400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number39228
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberV1780
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: