Healthcare Provider Details

I. General information

NPI: 1710907787
Provider Name (Legal Business Name): SHANE R HANSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 W 10TH ST
PANAMA CITY FL
32401-1444
US

IV. Provider business mailing address

2999 W 10TH ST
PANAMA CITY FL
32401-1444
US

V. Phone/Fax

Practice location:
  • Phone: 850-215-3339
  • Fax: 888-788-5217
Mailing address:
  • Phone: 850-215-3339
  • Fax: 888-788-5217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number19025779
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN17872
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: