Provider Demographics
NPI:1164540910
Name:HANSEN, THOMAS WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WALTER
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:792 6TH ST
Mailing Address - City:DAWSON
Mailing Address - State:MN
Mailing Address - Zip Code:56232-0456
Mailing Address - Country:US
Mailing Address - Phone:320-769-4756
Mailing Address - Fax:320-769-4756
Practice Address - Street 1:792 6TH ST
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:MN
Practice Address - Zip Code:56232-0456
Practice Address - Country:US
Practice Address - Phone:320-769-4756
Practice Address - Fax:320-769-4756
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist