Provider Demographics
NPI:1881755825
Name:HANNA, GEORGE (DMD)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:HANNA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204B NEEL AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801
Mailing Address - Country:US
Mailing Address - Phone:575-993-5032
Mailing Address - Fax:505-226-9697
Practice Address - Street 1:204B NEEL AVENUE
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:575-993-5032
Practice Address - Fax:505-226-9697
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411035122300000X
PADS036503122300000X
NMDD4651332B00000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89223829Medicaid