Provider Demographics
NPI:1851792683
Name:HANSEN, DOUGLAS (DMD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
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 1:13849 S PIONEER PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1904
Mailing Address - Country:US
Mailing Address - Phone:801-201-8366
Mailing Address - Fax:
Practice Address - Street 1:1256 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-8237
Practice Address - Country:US
Practice Address - Phone:801-607-5024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9141917-8903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist