Healthcare Provider Details

I. General information

NPI: 1003027400
Provider Name (Legal Business Name): JACE C. HANSEN DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 N. EAGLE RD.
BOISE ID
83713
US

IV. Provider business mailing address

6019 N. EAGLE RD.
BOISE ID
83713
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-2777
  • Fax: 208-377-3075
Mailing address:
  • Phone: 208-377-2777
  • Fax: 208-377-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-4290
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: