Provider Demographics
NPI:1689666232
Name:HANSON, PETER MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:HANSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-8345
Mailing Address - Country:US
Mailing Address - Phone:920-682-0321
Mailing Address - Fax:920-682-3128
Practice Address - Street 1:1503 RANDOLPH CT
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-8345
Practice Address - Country:US
Practice Address - Phone:920-682-0321
Practice Address - Fax:920-682-3128
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1679G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33545500Medicaid