Provider Demographics
NPI:1669785432
Name:HANSEN, JUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
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 1:710 NW JUNIPER ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2717
Mailing Address - Country:US
Mailing Address - Phone:428-837-0634
Mailing Address - Fax:425-837-0636
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE 206
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:428-837-0634
Practice Address - Fax:425-837-0636
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601695841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice