Provider Demographics
NPI:1831415447
Name:HANSEN, PAUL LLOYD (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LLOYD
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0458
Mailing Address - Country:US
Mailing Address - Phone:208-785-2685
Mailing Address - Fax:208-785-0998
Practice Address - Street 1:625 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2018
Practice Address - Country:US
Practice Address - Phone:208-785-2685
Practice Address - Fax:208-785-0998
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806356900Medicaid