Healthcare Provider Details

I. General information

NPI: 1023360963
Provider Name (Legal Business Name): KATHLEEN MARIE HANSON D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD V3 DENT
VANCOUVER WA
98661-3713
US

IV. Provider business mailing address

3710 SW US VETERANS HOSPITAL RD P3 DENT
PORTLAND OR
97239-2964
US

V. Phone/Fax

Practice location:
  • Phone: 360-619-5990
  • Fax:
Mailing address:
  • Phone: 503-220-8262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9873
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: