Provider Demographics
NPI:1124310685
Name:HANSEN, PRESTON (DDS)
Entity type:Individual
Prefix:
First Name:PRESTON
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 1:7138 S HIGHLAND DR
Mailing Address - Street 2:SUITE #211
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3757
Mailing Address - Country:US
Mailing Address - Phone:801-251-7167
Mailing Address - Fax:801-880-4559
Practice Address - Street 1:7138 S HIGHLAND DR
Practice Address - Street 2:SUITE #211
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3757
Practice Address - Country:US
Practice Address - Phone:801-251-7167
Practice Address - Fax:801-880-4559
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60916122300000X
TX308621223S0112X
UT99241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist