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General NPI Number Information
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NPI Number | 1376983213
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Entity Type | Organization
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Legal Business Name | THANE C. HISAW, DMD, PA
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Dates
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Enumeration Date | 06/25/2013
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Last Update Date | 06/27/2013
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Provider Practice Location Address
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Address Line | 504 E CORNWALLIS DR STE. J
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City | GREENSBORO
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State | NC
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Zip | 27405-5679
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Country | US
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Telephone | 336-378-1421
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Fax |
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Provider Business Mailing Address
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Address Line | 504 E CORNWALLIS DR STE. J
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City | GREENSBORO
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State | NC
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Zip | 27405-5679
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Country | US
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Telephone | 336-378-1421
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THANE HISAW
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Credential | DMD
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Telephone | 907-315-6812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 9508
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License Number State | NC
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