Provider Demographics
NPI:1578725842
Name:GREG A HANSON DDS PROF LLC
Entity Type:Organization
Organization Name:GREG A HANSON DDS PROF LLC
Other - Org Name:BOULEVARD DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-341-1895
Mailing Address - Street 1:801 MOUNT RUSHMORE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3614
Mailing Address - Country:US
Mailing Address - Phone:605-341-1895
Mailing Address - Fax:605-348-7177
Practice Address - Street 1:801 MOUNT RUSHMORE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3614
Practice Address - Country:US
Practice Address - Phone:605-341-1895
Practice Address - Fax:605-348-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty