Healthcare Provider Details

I. General information

NPI: 1124963004
Provider Name (Legal Business Name): ROBERT TRENT HANSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 REDWOOD LN UNIT 130
PUEBLO CO
81005-3292
US

IV. Provider business mailing address

4130 REDWOOD LN UNIT 130
PUEBLO CO
81005-3292
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-1102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00206698
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: