Provider Demographics
NPI:1356073993
Name:HANSON, TABITHA (DMD)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:HANSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19882 N 2100TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:IL
Mailing Address - Zip Code:62441-3529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441-1086
Practice Address - Country:US
Practice Address - Phone:217-826-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033725122300000X
IL019033725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist