Provider Demographics
NPI:1235497975
Name:HANSEN, GENTRY MICHAEL (DMD, MD)
Entity Type:Individual
Prefix:
First Name:GENTRY
Middle Name:MICHAEL
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5828 SUNNYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4253
Mailing Address - Country:US
Mailing Address - Phone:712-823-9654
Mailing Address - Fax:712-823-9008
Practice Address - Street 1:5828 SUNNYBROOK DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4253
Practice Address - Country:US
Practice Address - Phone:712-823-9654
Practice Address - Fax:712-823-9008
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD11971223S0112X
IA095131223S0112X
IA451691223S0112X
SD110021223S0112X
TX325671223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1548304710OtherDELTA DENTAL OF IA
IA1548304710OtherBC/BS OF IA
IA1548304710Medicaid
SD1548304710OtherBC/BS OF SD
NE91201365400Medicaid
SD1548304710OtherDELTA DENTAL OF SD