Provider Demographics
NPI:1851455703
Name:HANSEN, SCOTT S (DMD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:S
Last Name:HANSEN
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 1:501 NE HOOD AVE
Mailing Address - Street 2:SUITE 333
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7303
Mailing Address - Country:US
Mailing Address - Phone:503-661-2600
Mailing Address - Fax:503-661-2602
Practice Address - Street 1:501 NE HOOD AVE
Practice Address - Street 2:SUITE 333
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7303
Practice Address - Country:US
Practice Address - Phone:503-661-2600
Practice Address - Fax:503-661-2602
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012026Medicaid