Provider Demographics
NPI:1043658255
Name:HART, ROSS HAVENS (DDS)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:HAVENS
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 1:8225 N LOMBARD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3101
Mailing Address - Country:US
Mailing Address - Phone:971-413-0761
Mailing Address - Fax:
Practice Address - Street 1:8225 N LOMBARD ST STE 103
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3101
Practice Address - Country:US
Practice Address - Phone:971-413-0761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD103551223G0001X
MI2901020983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist