Provider Demographics
NPI:1730476987
Name:HANSEN, TIMOTHY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:S
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 1:1615 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0257
Mailing Address - Country:US
Mailing Address - Phone:507-289-3921
Mailing Address - Fax:507-288-2450
Practice Address - Street 1:1615 14TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-0257
Practice Address - Country:US
Practice Address - Phone:507-289-3921
Practice Address - Fax:507-288-2450
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND129981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND12998OtherMN DENTAL LICENSE #