Provider Demographics
NPI:1285981530
Name:HANSEN, JORDAN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:JOSEPH
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 1:169 N GATEWAY DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332
Mailing Address - Country:US
Mailing Address - Phone:435-241-7707
Mailing Address - Fax:435-514-6983
Practice Address - Street 1:169 N GATEWAY DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332
Practice Address - Country:US
Practice Address - Phone:435-241-7707
Practice Address - Fax:435-514-6983
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8362186-99221223E0200X
UT8362186-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist