Provider Demographics
NPI:1457467839
Name:HART, MARISA MARIE (DDS)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:MARIE
Last Name:HART
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 LAPEER
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1208
Mailing Address - Country:US
Mailing Address - Phone:989-759-6464
Mailing Address - Fax:989-399-8233
Practice Address - Street 1:2316 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3152
Practice Address - Country:US
Practice Address - Phone:517-887-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND801095OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI381908328OtherDELTA DENTAL OF MICHIGAN
MI1457467839Medicaid