Healthcare Provider Details

I. General information

NPI: 1174197867
Provider Name (Legal Business Name): SHANE S HANSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 411 BOX 4187
APO AE
09112-0042
US

IV. Provider business mailing address

PSC 411 BOX 4187
APO AE
09112-0042
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone: 555-555-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61181691
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: