Provider Demographics
NPI:1710907787
Name:HANSON, SHANE R (DMD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:R
Last Name:HANSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-1444
Mailing Address - Country:US
Mailing Address - Phone:850-215-3339
Mailing Address - Fax:888-788-5217
Practice Address - Street 1:2999 W 10TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1444
Practice Address - Country:US
Practice Address - Phone:850-215-3339
Practice Address - Fax:888-788-5217
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190257791223E0200X
FLDN178721223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics