Provider Demographics
NPI:1043949860
Name:HANSON, CALLIE JO (RDH, MDT)
Entity Type:Individual
Prefix:MISS
First Name:CALLIE
Middle Name:JO
Last Name:HANSON
Suffix:
Gender:F
Credentials:RDH, MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 HOEGER LN
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-4220
Mailing Address - Country:US
Mailing Address - Phone:507-383-3549
Mailing Address - Fax:
Practice Address - Street 1:309 HOLLY LN
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5422
Practice Address - Country:US
Practice Address - Phone:507-388-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH11186124Q00000X
MNDT151125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist