Provider Demographics
NPI:1295841351
Name:HANSELMAN, MARK RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:HANSELMAN
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 1:4706 PARKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9440
Mailing Address - Country:US
Mailing Address - Phone:734-913-8121
Mailing Address - Fax:
Practice Address - Street 1:1303 PACKARD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-3874
Practice Address - Country:US
Practice Address - Phone:734-769-1130
Practice Address - Fax:734-769-2816
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice