MEDICARE: DR. CHARLES WALDEN HANNA DMD

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	122300000X	Dentist	1631	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720138852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES WALDEN HANNA DMD

Provider Business Mailing Address
First Line	:	PO BOX 2409
Second Line	:	121 NORTH PINE STREET
City	:	BATESBURG LEESVILLE
State	:	SC
Zip	:	29070-0409
Country	:	US
Telephone Number	:	803-532-6146
Fax Number	:	803-532-5807

Provider Business Practice Location Address
First Line	:	121 NORTH PINE STREET
Second Line	:
City	:	BATESBURG LEESVILLE
State	:	SC
Zip	:	29006
Country	:	US
Telephone Number	:	803-532-6146
Fax Number	:	803-532-5807

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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