Healthcare Provider Details

I. General information

NPI: 1053005603
Provider Name (Legal Business Name): HAE JIN HAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 UNSER BLVD SE STE 100
RIO RANCHO NM
87124-6376
US

IV. Provider business mailing address

950 UNSER BLVD SE STE 100
RIO RANCHO NM
87124-6376
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-2900
  • Fax:
Mailing address:
  • Phone: 505-892-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDB-2025-0502
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: