Provider Demographics
NPI:1851798045
Name:BRYCE D HANSON, DMD PA
Entity Type:Organization
Organization Name:BRYCE D HANSON, DMD PA
Other - Org Name:RIVER VALLEY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-357-7611
Mailing Address - Street 1:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-0525
Mailing Address - Country:US
Mailing Address - Phone:208-357-7611
Mailing Address - Fax:208-357-1805
Practice Address - Street 1:371 W FIR ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1456
Practice Address - Country:US
Practice Address - Phone:208-357-7611
Practice Address - Fax:208-357-1805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3275261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025-57200Medicaid
ID119-477-4109Medicaid
ID8050-31700Medicaid