Healthcare Provider Details

I. General information

NPI: 1699187252
Provider Name (Legal Business Name): JASON R HANSEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 E SKYLINE DR STE 100
SOUTH OGDEN UT
84405-4847
US

IV. Provider business mailing address

1508 E SKYLINE DR STE 100
SOUTH OGDEN UT
84405-4847
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-7069
  • Fax: 801-479-7100
Mailing address:
  • Phone: 801-479-7069
  • Fax: 801-479-7100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12032337
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: