Provider Demographics
NPI:1033628920
Name:MACK AND HANSEN ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:MACK AND HANSEN ORTHODONTICS, PLLC
Other - Org Name:MACK AND HANSEN ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:MCKENZIE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:903-212-7737
Mailing Address - Street 1:1405 JUDSON RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3918
Mailing Address - Country:US
Mailing Address - Phone:903-212-7737
Mailing Address - Fax:903-212-7745
Practice Address - Street 1:1405 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-3918
Practice Address - Country:US
Practice Address - Phone:903-212-7737
Practice Address - Fax:903-212-7745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-24
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223X0400X, 261QD0000X
TX30007261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental