Provider Demographics
NPI:1003858630
Name:GUY M. HANSON, DDS, PA
Entity type:Organization
Organization Name:GUY M. HANSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-375-1012
Mailing Address - Street 1:9203 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2502
Mailing Address - Country:US
Mailing Address - Phone:208-375-1012
Mailing Address - Fax:208-375-1098
Practice Address - Street 1:9203 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2502
Practice Address - Country:US
Practice Address - Phone:208-375-1012
Practice Address - Fax:208-375-1098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1850261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center