MEDICARE: ERIC D. HANSON D.D.S., P.C.

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	261QD0000X	Dental Clinic/Center	6093	OK

General Provider Information

NPI Number	:	1558683102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERIC D. HANSON D.D.S., P.C.

Provider Business Mailing Address
First Line	:	2820 NW 32ND ST
Second Line	:
City	:	NEWCASTLE
State	:	OK
Zip	:	73065-6576
Country	:	US
Telephone Number	:	405-392-4883
Fax Number	:	405-392-4889

Provider Business Practice Location Address
First Line	:	2820 NW 32ND ST
Second Line	:
City	:	NEWCASTLE
State	:	OK
Zip	:	73065-6576
Country	:	US
Telephone Number	:	405-392-4883
Fax Number	:	405-392-4889

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KIM BUIE
Credential	:
Telephone Number	:	405-392-4883

Provider Enumeration Date	:	02/24/2010
Last Update Date	:	02/24/2010

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