Provider Demographics
NPI:1649317702
Name:HANNE, SHARON E (DMD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:E
Last Name:HANNE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 EDWARDSVILLE CROSSING DR STE D
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2708
Mailing Address - Country:US
Mailing Address - Phone:618-972-8655
Mailing Address - Fax:618-692-6975
Practice Address - Street 1:6655 EDWARDSVILLE CROSSING DR STE D
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2708
Practice Address - Country:US
Practice Address - Phone:618-972-8655
Practice Address - Fax:618-692-6975
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0158671223G0001X
IL019.024344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO403393918Medicaid