Provider Demographics
NPI:1922171024
Name:HANSEN, CARL ARTHUR (DDS)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:ARTHUR
Last Name:HANSEN
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:PO BOX 508
Mailing Address - Street 2:215 N COURT
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840
Mailing Address - Country:US
Mailing Address - Phone:304-574-1363
Mailing Address - Fax:304-574-1363
Practice Address - Street 1:215 NORTH COURT ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840
Practice Address - Country:US
Practice Address - Phone:304-574-1363
Practice Address - Fax:304-574-1363
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135245000Medicaid