=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457055618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENNAN GARTH HANSEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2023
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4616 MONTEVALLO RD
-----------------------------------------------------
City | IRONDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35210-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-202-9540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1691 ASHWOOD LN
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209-1259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-315-7301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D.007223-C1
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------