Healthcare Provider Details

I. General information

NPI: 1720214935
Provider Name (Legal Business Name): DALLAS GREGORY HANSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 937-679-6276
  • Fax:
Mailing address:
  • Phone: 513-585-5506
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101248965
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number35132197
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35132197
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: