Healthcare Provider Details

I. General information

NPI: 1679220818
Provider Name (Legal Business Name): BLAINE R HANSEN, DMD, MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 N BUFFALO DR STE 110
LAS VEGAS NV
89129-7462
US

IV. Provider business mailing address

3600 N BUFFALO DR STE 110
LAS VEGAS NV
89129-7462
US

V. Phone/Fax

Practice location:
  • Phone: 702-568-1600
  • Fax: 702-568-1983
Mailing address:
  • Phone: 702-568-1600
  • Fax: 702-568-1983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CINDY BAKER
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 702-568-1600