Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | D-4290 | ID |
NPI | 1003027400 |
---|---|
Provider Name | Dr. Jace C. Hansen |
First Address | Boise, ID 83713 |
Second Address | Boise, ID 83713 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2007 |
Last Update Date | 23/06/2021 |