Healthcare Provider Details

I. General information

NPI: 1467493130
Provider Name (Legal Business Name): DR. STEPHEN JEWELL HANSARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 S GREENWOOD ST
LAGRANGE GA
30240-3128
US

IV. Provider business mailing address

606 S GREENWOOD ST P O BOX 2030
LAGRANGE GA
30240-3128
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-5551
  • Fax: 706-812-8558
Mailing address:
  • Phone: 706-882-5551
  • Fax: 706-812-8558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN010845
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: