Provider Demographics
NPI:1437955861
Name:KHALIQ, HASAN
Entity type:Individual
Prefix:
First Name:HASAN
Middle Name:
Last Name:KHALIQ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 HIDDEN VALLEY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-8022
Mailing Address - Country:US
Mailing Address - Phone:949-232-3109
Mailing Address - Fax:
Practice Address - Street 1:3890 DIXIE HWY STE 1A
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-4205
Practice Address - Country:US
Practice Address - Phone:989-777-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602563122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program