Provider Demographics
NPI:1588194294
Name:HANSEN, EMILY MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:MARIE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W KINZIE ST APT 3001
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5859
Mailing Address - Country:US
Mailing Address - Phone:708-269-1449
Mailing Address - Fax:
Practice Address - Street 1:9307 CALUMET AVE STE D2
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2892
Practice Address - Country:US
Practice Address - Phone:219-836-2910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012759A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist