Provider Demographics
NPI:1558458281
Name:J CLAYTON HANSEN DDS PLLC
Entity Type:Organization
Organization Name:J CLAYTON HANSEN DDS PLLC
Other - Org Name:PALOUSE VIEW DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-882-4923
Mailing Address - Street 1:1526 S LEVICK ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2560
Mailing Address - Country:US
Mailing Address - Phone:208-882-4923
Mailing Address - Fax:208-882-8418
Practice Address - Street 1:1526 S LEVICK ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2560
Practice Address - Country:US
Practice Address - Phone:208-882-4923
Practice Address - Fax:208-882-8418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty