Provider Demographics
NPI:1982704094
Name:HANSEN, ANTHONY J (LD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:HANSEN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 WOBURN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-5643
Mailing Address - Country:US
Mailing Address - Phone:360-738-1177
Mailing Address - Fax:360-738-1192
Practice Address - Street 1:3410 WOBURN ST STE 201
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5643
Practice Address - Country:US
Practice Address - Phone:360-738-1177
Practice Address - Fax:360-738-1192
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000392122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047444Medicaid