Provider Demographics
NPI:1790868024
Name:CHARLES EDWARD HANNA
Entity Type:Organization
Organization Name:CHARLES EDWARD HANNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-631-2900
Mailing Address - Street 1:1504 HARCREST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640
Mailing Address - Country:US
Mailing Address - Phone:989-631-2900
Mailing Address - Fax:989-631-2915
Practice Address - Street 1:1504 HARCREST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-631-2900
Practice Address - Fax:989-631-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI085771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4004330Medicaid
MI=========OtherTAX ID
MI4004330Medicaid