=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295292340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB JOHNSON HANSEEN DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2019
-----------------------------------------------------
Last Update Date | 02/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 N PENNSYLVANIA AVE
-----------------------------------------------------
City | GLENDORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91741-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-963-4173
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 518 MAGNOLIA ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80220-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-918-3866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 103563
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------