Provider Demographics
NPI:1538580113
Name:HANSTAD, BRIAN T (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:HANSTAD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 N. CITRUS LN
Mailing Address - Street 2:ASPC-PERRYVILLE
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85395
Mailing Address - Country:US
Mailing Address - Phone:702-808-6530
Mailing Address - Fax:
Practice Address - Street 1:2105 N. CITRUS LN
Practice Address - Street 2:ASPC-PERRYVILLE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:702-808-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD076031223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health