Provider Demographics
NPI:1174294136
Name:HANSEN, CORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:HANSEN
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 1:618 GAMBELL ST APT 22
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3797
Mailing Address - Country:US
Mailing Address - Phone:417-380-8848
Mailing Address - Fax:
Practice Address - Street 1:6611 DEBARR RD STE 200
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1796
Practice Address - Country:US
Practice Address - Phone:888-496-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK180475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist