Provider Demographics
NPI:1053632919
Name:CHRIS HANSEN DMD PA
Entity type:Organization
Organization Name:CHRIS HANSEN DMD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-233-5362
Mailing Address - Street 1:333 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5045
Mailing Address - Country:US
Mailing Address - Phone:208-233-5362
Mailing Address - Fax:208-234-8056
Practice Address - Street 1:333 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5045
Practice Address - Country:US
Practice Address - Phone:208-233-5362
Practice Address - Fax:208-234-8056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty