Provider Demographics
NPI:1730297904
Name:HART, KEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
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 1:1922 PLAEN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-4437
Mailing Address - Country:US
Mailing Address - Phone:319-936-7898
Mailing Address - Fax:
Practice Address - Street 1:113 W MARENGO RD
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:IA
Practice Address - Zip Code:52340-9212
Practice Address - Country:US
Practice Address - Phone:319-545-7630
Practice Address - Fax:319-545-7749
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0465088Medicaid