Provider Demographics
NPI:1265642854
Name:HANSEN, JODY ERIC (LD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:ERIC
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2411
Mailing Address - Country:US
Mailing Address - Phone:360-676-1499
Mailing Address - Fax:360-738-2281
Practice Address - Street 1:2710 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2411
Practice Address - Country:US
Practice Address - Phone:360-676-1499
Practice Address - Fax:360-738-2281
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000002122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADN00000002OtherWA DENTURIST LICENSE #
WA5020052Medicaid