MEDICARE: GENTRY MICHAEL HANSEN DMD, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D1197	SD
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	09513	IA
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	45169	IA
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	11002	SD
5	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	32567	TX

General Provider Information

NPI Number	:	1235497975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENTRY MICHAEL HANSEN DMD, MD

Provider Business Mailing Address
First Line	:	5828 SUNNYBROOK DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4253
Country	:	US
Telephone Number	:	712-823-9654
Fax Number	:	712-823-9008

Provider Business Practice Location Address
First Line	:	5828 SUNNYBROOK DR
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51106-4253
Country	:	US
Telephone Number	:	712-823-9654
Fax Number	:	712-823-9008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	03/07/2024

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