Provider Demographics
NPI:1023160157
Name:LABRUCE M HANAHAN JR DMD PA
Entity type:Organization
Organization Name:LABRUCE M HANAHAN JR DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LABRUCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HANAHAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-792-4630
Mailing Address - Street 1:1817 W MAIN ST SUITE 2
Mailing Address - Street 2:
Mailing Address - City:DOTHAM
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-792-4630
Mailing Address - Fax:334-712-0190
Practice Address - Street 1:1817 W MAIN ST SUITE 2
Practice Address - Street 2:
Practice Address - City:DOTHAM
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-792-4630
Practice Address - Fax:334-712-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BH7505487OtherDEA
AH0459138OtherDEA
BF8986311OtherDEA