MEDICARE: CHARLES B. HANNA, JR., D.M.D.

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	1223G0001X	General Practice Dentistry	4359	SC
2	1223G0001X	General Practice Dentistry	1847	SC

General Provider Information

NPI Number	:	1871784488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES B. HANNA, JR., D.M.D.

Provider Business Mailing Address
First Line	:	PO BOX 161899
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-0032
Country	:	US
Telephone Number	:	864-578-8344
Fax Number	:	864-578-9255

Provider Business Practice Location Address
First Line	:	1821 OLD FURNACE RD
Second Line	:
City	:	BOILING SPRINGS
State	:	SC
Zip	:	29316-7427
Country	:	US
Telephone Number	:	864-578-8344
Fax Number	:	864-578-9255

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CHARLES B. HANNA JR.
Credential	:	D.M.D.
Telephone Number	:	864-578-8344

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	08/08/2007

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