Basic Information
| Provider Information | |||||||||
| NPI: | 1063493724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSILL | ||||||||
| FirstName: | MARNI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MDM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | NYSSA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979133477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413722606 | ||||||||
| FaxNumber: | 5413725732 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | NYSSA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979133477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413722606 | ||||||||
| FaxNumber: | 5413725732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D8671 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D8671 | 01 | OR | DENTAL LICENSE | OTHER |