Provider Demographics
NPI:1487489753
Name:HANSEMANN, NICHOLAS AIDAN (LD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:AIDAN
Last Name:HANSEMANN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3365 COLTON DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-0265
Mailing Address - Country:US
Mailing Address - Phone:406-438-1455
Mailing Address - Fax:
Practice Address - Street 1:3365 COLTON DR UNIT A
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0265
Practice Address - Country:US
Practice Address - Phone:406-438-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT28511122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist