Provider Demographics
NPI:1720001761
Name:HANSON, BRUCE W (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
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 1:25052 104TH AVE SE STE D
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-6853
Mailing Address - Country:US
Mailing Address - Phone:253-852-4508
Mailing Address - Fax:253-859-9306
Practice Address - Street 1:25052 104TH AVE SE STE D
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6853
Practice Address - Country:US
Practice Address - Phone:253-852-4508
Practice Address - Fax:253-859-9306
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000050131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5539309Medicaid