=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033628920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACK AND HANSEN ORTHODONTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2017
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 JUDSON RD
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-212-7737
-----------------------------------------------------
Fax | 903-212-7745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 JUDSON RD
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-212-7737
-----------------------------------------------------
Fax | 903-212-7745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ORTHODONTIST
-----------------------------------------------------
Name | SPENCER MCKENZIE MACK
-----------------------------------------------------
Credential | DDS, MSD
-----------------------------------------------------
Telephone | 903-212-7737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 30007
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------