Healthcare Provider Details

I. General information

NPI: 1033628920
Provider Name (Legal Business Name): MACK AND HANSEN ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2017
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 JUDSON RD
LONGVIEW TX
75601-3918
US

IV. Provider business mailing address

1405 JUDSON RD
LONGVIEW TX
75601-3918
US

V. Phone/Fax

Practice location:
  • Phone: 903-212-7737
  • Fax: 903-212-7745
Mailing address:
  • Phone: 903-212-7737
  • Fax: 903-212-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number30007
License Number StateTX

VIII. Authorized Official

Name: SPENCER MCKENZIE MACK
Title or Position: OWNER/ORTHODONTIST
Credential: DDS, MSD
Phone: 903-212-7737