=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669068466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HANAA'S LEGACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2020
-----------------------------------------------------
Last Update Date | 12/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 CHESTNUT ST
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-4320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-320-9320
-----------------------------------------------------
Fax | 973-587-8766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 187 CHESTNUT ST
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-4320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-320-9320
-----------------------------------------------------
Fax | 973-587-8766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIAM HABIB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-937-9344
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------