Provider Demographics
NPI:1871603498
Name:CHRIS J. HANSEN, DDS, SC
Entity type:Organization
Organization Name:CHRIS J. HANSEN, DDS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-684-0123
Mailing Address - Street 1:1415 NORTH 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-2051
Mailing Address - Country:US
Mailing Address - Phone:920-684-0123
Mailing Address - Fax:920-682-7374
Practice Address - Street 1:1415 NORTH 8TH STREET
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2051
Practice Address - Country:US
Practice Address - Phone:920-684-0123
Practice Address - Fax:920-682-7374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38394200Medicaid