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General NPI Number Information
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NPI Number | 1851798045
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Entity Type | Organization
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Legal Business Name | BRYCE D HANSON, DMD PA
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Dates
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Enumeration Date | 12/03/2014
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Last Update Date | 12/03/2014
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Provider Practice Location Address
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Address Line | 371 W FIR ST
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City | SHELLEY
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State | ID
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Zip | 83274-1456
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Country | US
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Telephone | 208-357-7611
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Fax | 208-357-1805
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Provider Business Mailing Address
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Address Line | PO BOX 525
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City | SHELLEY
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State | ID
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Zip | 83274-0525
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Country | US
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Telephone | 208-357-7611
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Fax | 208-357-1805
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRYCE D HANSON
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Credential | DMD
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Telephone | 208-357-7611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D-3275
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License Number State | ID
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