Provider Demographics
NPI:1285858605
Name:HANSEN, MARK ANDRE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDRE
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 NOVATO BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947
Mailing Address - Country:US
Mailing Address - Phone:415-897-5070
Mailing Address - Fax:415-897-8805
Practice Address - Street 1:1730 NOVATO BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947
Practice Address - Country:US
Practice Address - Phone:415-897-5070
Practice Address - Fax:415-897-8805
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice