Provider Demographics
NPI:1902023450
Name:HANNEMAN, CHAD RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:RAYMOND
Last Name:HANNEMAN
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 1:2441 CORAL COURT #5
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241
Mailing Address - Country:US
Mailing Address - Phone:319-545-6251
Mailing Address - Fax:319-545-7265
Practice Address - Street 1:2441 CORAL COURT #5
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241
Practice Address - Country:US
Practice Address - Phone:319-545-6251
Practice Address - Fax:319-545-7265
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA80011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1219089Medicaid
IA20737OtherBCBS
IA1382746OtherCONCORDIA