Healthcare Provider Details

I. General information

NPI: 1164540910
Provider Name (Legal Business Name): THOMAS WALTER HANSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 6TH ST
DAWSON MN
56232-0456
US

IV. Provider business mailing address

PO BOX 456 792 6TH ST
DAWSON MN
56232-0456
US

V. Phone/Fax

Practice location:
  • Phone: 320-769-4756
  • Fax: 320-769-4756
Mailing address:
  • Phone: 320-769-4756
  • Fax: 320-769-4756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9171
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: