Provider Demographics
NPI:1245969054
Name:HANSEN, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1934
Mailing Address - Country:US
Mailing Address - Phone:385-219-0372
Mailing Address - Fax:
Practice Address - Street 1:2592 S 5600 W STE 102
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-1274
Practice Address - Country:US
Practice Address - Phone:801-613-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12885953-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist