Provider Demographics
NPI:1043365935
Name:HANSSEN, OTTO JULIUS (DDS)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:JULIUS
Last Name:HANSSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21515 STATE ROUTE 410 E
Mailing Address - Street 2:SUITE A
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-4100
Mailing Address - Country:US
Mailing Address - Phone:253-826-9000
Mailing Address - Fax:253-826-0328
Practice Address - Street 1:21515 STATE ROUTE 410 E
Practice Address - Street 2:SUITE A
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-4100
Practice Address - Country:US
Practice Address - Phone:253-826-9000
Practice Address - Fax:253-826-0328
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000052621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice