Provider Demographics
NPI:1376983213
Name:THANE C. HISAW, DMD, PA
Entity Type:Organization
Organization Name:THANE C. HISAW, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HISAW
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:907-315-6812
Mailing Address - Street 1:504 E CORNWALLIS DR
Mailing Address - Street 2:STE. J
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5679
Mailing Address - Country:US
Mailing Address - Phone:336-378-1421
Mailing Address - Fax:
Practice Address - Street 1:504 E CORNWALLIS DR
Practice Address - Street 2:STE. J
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5679
Practice Address - Country:US
Practice Address - Phone:336-378-1421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty