Provider Demographics
NPI:1326102211
Name:HANSEN, BLAINE R (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 N BUFFALO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-7444
Mailing Address - Country:US
Mailing Address - Phone:702-568-1600
Mailing Address - Fax:
Practice Address - Street 1:3600 N BUFFALO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7444
Practice Address - Country:US
Practice Address - Phone:702-568-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65731223X0400X
UT512340299211223X0400X
NVS3-152C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics