MEDICARE: DR. BLAINE R HANSEN DMD, MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6573	AZ
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	51234029921	UT
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	S3-152C	NV

General Provider Information

NPI Number	:	1326102211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAINE R HANSEN DMD, MS

Provider Business Mailing Address
First Line	:	3600 N BUFFALO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7444
Country	:	US
Telephone Number	:	702-568-1600
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 N BUFFALO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7444
Country	:	US
Telephone Number	:	702-568-1600
Fax Number	:

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	11/02/2007

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