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General NPI Number Information
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NPI Number | 1558458281
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Entity Type | Organization
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Legal Business Name | J CLAYTON HANSEN DDS PLLC
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 04/26/2012
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Provider Practice Location Address
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Address Line | 1526 S LEVICK ST
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City | MOSCOW
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State | ID
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Zip | 83843-2560
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Country | US
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Telephone | 208-882-4923
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Fax | 208-882-8418
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Provider Business Mailing Address
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Address Line | 1526 S LEVICK ST
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City | MOSCOW
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State | ID
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Zip | 83843-2560
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Country | US
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Telephone | 208-882-4923
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Fax | 208-882-8418
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | JAY CLAYTON HANSEN
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Credential | DDS
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Telephone | 208-882-4923
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3853
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License Number State | ID
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