MEDICARE: BLAINE R HANSEN, DMD, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679220818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAINE R HANSEN, DMD, MS

Provider Business Mailing Address
First Line	:	3600 N BUFFALO DR STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7462
Country	:	US
Telephone Number	:	702-568-1600
Fax Number	:	702-568-1983

Provider Business Practice Location Address
First Line	:	3600 N BUFFALO DR STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7462
Country	:	US
Telephone Number	:	702-568-1600
Fax Number	:	702-568-1983

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	CINDY BAKER
Credential	:
Telephone Number	:	702-568-1600

Provider Enumeration Date	:	03/08/2022
Last Update Date	:	03/08/2022

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