Provider Demographics
NPI:1083874812
Name:HART, WILLIAM R (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:HART
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10655 STATE RD 662
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630
Mailing Address - Country:US
Mailing Address - Phone:812-853-3313
Mailing Address - Fax:
Practice Address - Street 1:10655 STATE RD 662
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630
Practice Address - Country:US
Practice Address - Phone:812-853-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12005552A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100344430AMedicaid