Provider Demographics
NPI:1295292340
Name:HANSEEN, JACOB JOHNSON (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHNSON
Last Name:HANSEEN
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 1:518 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-6014
Mailing Address - Country:US
Mailing Address - Phone:801-918-3866
Mailing Address - Fax:
Practice Address - Street 1:175 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3316
Practice Address - Country:US
Practice Address - Phone:626-963-4173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1035631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty