Provider Demographics
NPI:1467493130
Name:HANSARD, STEPHEN JEWELL
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JEWELL
Last Name:HANSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S GREENWOOD ST
Mailing Address - Street 2:P O BOX 2030
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3128
Mailing Address - Country:US
Mailing Address - Phone:706-882-5551
Mailing Address - Fax:706-812-8558
Practice Address - Street 1:606 S GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3128
Practice Address - Country:US
Practice Address - Phone:706-882-5551
Practice Address - Fax:706-812-8558
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000422463DMedicaid