=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881376598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIVIANA HAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2023
-----------------------------------------------------
Last Update Date | 08/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5562 PHILADELPHIA ST STE 211
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-2499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-548-0557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 W LA HABRA BLVD UNIT 104
-----------------------------------------------------
City | LA HABRA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90631-5232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-261-0726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 107304
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------