Provider Demographics
NPI:1457733529
Name:HART, MANERVA JEANETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANERVA
Middle Name:JEANETTE
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 1:1710 NE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1939
Mailing Address - Country:US
Mailing Address - Phone:503-740-2479
Mailing Address - Fax:
Practice Address - Street 1:1710 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1939
Practice Address - Country:US
Practice Address - Phone:503-295-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100438122300000X
ORD11725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist