Basic Information
| Provider Information | |||||||||
| NPI: | 1154548519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032864560 | ||||||||
| FaxNumber: | 3032864589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 2ND ST | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038572771 | ||||||||
| FaxNumber: | 7203229434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 904065 | CO | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 60834323 | 05 | CO | MEDICAID |