Healthcare Provider Details

I. General information

NPI: 1326102211
Provider Name (Legal Business Name): BLAINE R HANSEN DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 N BUFFALO DR
LAS VEGAS NV
89129-7444
US

IV. Provider business mailing address

3600 N BUFFALO DR
LAS VEGAS NV
89129-7444
US

V. Phone/Fax

Practice location:
  • Phone: 702-568-1600
  • Fax:
Mailing address:
  • Phone: 702-568-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6573
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51234029921
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberS3-152C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: