Healthcare Provider Details

I. General information

NPI: 1144679275
Provider Name (Legal Business Name): ROBERT HANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 EAGLE RANCH RD NW
ALBUQUERQUE NM
87114-6032
US

IV. Provider business mailing address

9201 EAGLE RANCH RD
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-9010
  • Fax:
Mailing address:
  • Phone: 505-892-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD4517
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: