Healthcare Provider Details

I. General information

NPI: 1710299433
Provider Name (Legal Business Name): AUSTIN CREEK DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2010
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:
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 NumberD-3513
License Number StateID

VIII. Authorized Official

Name: DR. TIMOTHY A HANSEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 208-938-1825