MEDICARE: PRESTON G. HANSEN, DDS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1154947372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTON G. HANSEN, DDS, PLLC

Provider Business Mailing Address
First Line	:	7138 S HIGHLAND DR STE 211
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3787
Country	:	US
Telephone Number	:	801-251-7167
Fax Number	:	801-880-4559

Provider Business Practice Location Address
First Line	:	7138 S HIGHLAND DR STE 211
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3787
Country	:	US
Telephone Number	:	801-251-7167
Fax Number	:	801-880-4559

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PRESTON HANSEN
Credential	:	DDS
Telephone Number	:	801-251-7167

Provider Enumeration Date	:	06/23/2020
Last Update Date	:	06/23/2020

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