Healthcare Provider Details

I. General information

NPI: 1215911920
Provider Name (Legal Business Name): TIMOTHY A HANSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 N PENNGROVE WAY STE 100
MERIDIAN ID
83646-7449
US

IV. Provider business mailing address

4702 N PENNGROVE WAY STE 100
MERIDIAN ID
83646-7449
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-1825
  • Fax: 208-938-5763
Mailing address:
  • Phone: 208-938-1825
  • Fax: 208-938-5763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3513
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: