Healthcare Provider Details

I. General information

NPI: 1891867875
Provider Name (Legal Business Name): JERRY C. HAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W CLEARWATER AVE
KENNEWICK WA
99336-1964
US

IV. Provider business mailing address

5000 W CLEARWATER AVE
KENNEWICK WA
99336-1910
US

V. Phone/Fax

Practice location:
  • Phone: 509-783-5000
  • Fax: 509-783-8349
Mailing address:
  • Phone: 509-783-5000
  • Fax: 509-783-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number00008483
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00008483
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code125Q00000X
TaxonomyOral Medicine Dentistry
License Number00008483
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number00008483
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: