Provider Demographics
NPI:1477634210
Name:HANSON, DAVID HERBERT (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:HERBERT
Last Name:HANSON
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 KERI LN
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6865
Mailing Address - Country:US
Mailing Address - Phone:630-887-8124
Mailing Address - Fax:
Practice Address - Street 1:2449 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2414
Practice Address - Country:US
Practice Address - Phone:773-327-2400
Practice Address - Fax:773-327-4759
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG88966Medicare UPIN
IL537180Medicare ID - Type UnspecifiedPROVIDER #