Provider Demographics
NPI:1114059037
Name:HANSEN, MICHAEL R (DR DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DR DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25350 #A MARGUERITE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2908
Mailing Address - Country:US
Mailing Address - Phone:949-859-6549
Mailing Address - Fax:949-859-6540
Practice Address - Street 1:25350 #A MARGUERITE PARKWAY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-2908
Practice Address - Country:US
Practice Address - Phone:949-859-6549
Practice Address - Fax:949-859-6540
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice