Provider Demographics
NPI:1194926527
Name:CHARLES E. MONTOURE, DDS, MS MARK H HANSON, DDS, MS, SC
Entity type:Organization
Organization Name:CHARLES E. MONTOURE, DDS, MS MARK H HANSON, DDS, MS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORP
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MONTOURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:920-499-3721
Mailing Address - Street 1:2000 SHADY LANE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9311
Mailing Address - Country:US
Mailing Address - Phone:920-499-3721
Mailing Address - Fax:920-499-7502
Practice Address - Street 1:2000 SHADY LANE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-9311
Practice Address - Country:US
Practice Address - Phone:920-499-3721
Practice Address - Fax:920-499-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty