Provider Demographics
NPI:1336505635
Name:HANSEN, SPENCER MACK
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:MACK
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SPENCER
Other - Middle Name:MCKENZIE
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1405 JUDSON RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3918
Mailing Address - Country:US
Mailing Address - Phone:903-212-7737
Mailing Address - Fax:
Practice Address - Street 1:1405 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-3918
Practice Address - Country:US
Practice Address - Phone:903-212-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics