Provider Demographics
NPI:1003027400
Name:HANSEN, JACE C (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACE
Middle Name:C
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6019 N. EAGLE RD.
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713
Mailing Address - Country:US
Mailing Address - Phone:208-377-2777
Mailing Address - Fax:208-377-3075
Practice Address - Street 1:6019 N. EAGLE RD.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-377-2777
Practice Address - Fax:208-377-3075
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-42901223P0300X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program