Healthcare Provider Details

I. General information

NPI: 1013122357
Provider Name (Legal Business Name): JAMES T HANSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 MILTON AVE
BALLSTON SPA NY
12020-1405
US

IV. Provider business mailing address

1458 DIVISION ST
CHARLTON NY
12019-2917
US

V. Phone/Fax

Practice location:
  • Phone: 518-885-1791
  • Fax: 518-885-1147
Mailing address:
  • Phone: 518-882-9342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046659
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: