Healthcare Provider Details

I. General information

NPI: 1386931095
Provider Name (Legal Business Name): JOHN TIMOTHY HANSFORD JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 JERICHO TPKE
COMMACK NY
11725-2937
US

IV. Provider business mailing address

102 NORMAN AVE
BROOKLYN NY
11222-2934
US

V. Phone/Fax

Practice location:
  • Phone: 631-486-6364
  • Fax:
Mailing address:
  • Phone: 929-324-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number056107
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number056107
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: