Provider Demographics
NPI:1427180801
Name:HISAW, THANE C (DMD)
Entity Type:Individual
Prefix:
First Name:THANE
Middle Name:C
Last Name:HISAW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 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:336-273-5065
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:336-273-5065
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC90581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry