Provider Demographics
NPI:1386931095
Name:HANSFORD, JOHN TIMOTHY JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TIMOTHY
Last Name:HANSFORD
Suffix:JR
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 1:102 NORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-2934
Mailing Address - Country:US
Mailing Address - Phone:929-324-1140
Mailing Address - Fax:
Practice Address - Street 1:2171 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2937
Practice Address - Country:US
Practice Address - Phone:631-486-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0561071223P0221X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223D0004XDental ProvidersDentistDental Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131740114Medicaid