Provider Demographics
NPI:1942375894
Name:HANSEN, DOUGLAS A (DDS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
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 1:4507 CHADWICK RD
Mailing Address - Street 2:
Mailing Address - City:CEDER FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613
Mailing Address - Country:US
Mailing Address - Phone:319-266-1433
Mailing Address - Fax:319-266-3749
Practice Address - Street 1:4507 CHADWICK RD
Practice Address - Street 2:
Practice Address - City:CEDER FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613
Practice Address - Country:US
Practice Address - Phone:319-266-1433
Practice Address - Fax:319-266-3749
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2236588Medicaid