Provider Demographics
NPI:1073240081
Name:HANRAHAN, MACAELAN COLLINS (DMD)
Entity Type:Individual
Prefix:
First Name:MACAELAN
Middle Name:COLLINS
Last Name:HANRAHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 NE 162ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5642
Mailing Address - Country:US
Mailing Address - Phone:503-257-0162
Mailing Address - Fax:503-251-2330
Practice Address - Street 1:1850 NE 162ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5642
Practice Address - Country:US
Practice Address - Phone:503-257-0162
Practice Address - Fax:503-251-2330
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11653122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD11653Medicaid