Provider Demographics
NPI:1700135886
Name:SPA DENTAL, PC
Entity Type:Organization
Organization Name:SPA DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:D,MD
Authorized Official - Phone:518-885-1791
Mailing Address - Street 1:68 MILTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:518-885-1791
Mailing Address - Fax:518-885-1147
Practice Address - Street 1:68 MILTON AVENUE
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020
Practice Address - Country:US
Practice Address - Phone:518-885-1791
Practice Address - Fax:518-885-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03275514Medicaid