Provider Demographics
NPI:1649350166
Name:HART, JON R (DDS)
Entity type:Individual
Prefix:DR
First Name:JON
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 1:108 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1319
Mailing Address - Country:US
Mailing Address - Phone:563-382-3657
Mailing Address - Fax:563-382-0739
Practice Address - Street 1:108 5TH AVE
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-1319
Practice Address - Country:US
Practice Address - Phone:563-382-3657
Practice Address - Fax:563-382-0739
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA59911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA863395OtherUNITED CONCORDIA ID
IA0014795Medicaid