Provider Demographics
NPI:1578676029
Name:HARTY, DOUGLAS R (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:HARTY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2801 FAIRVIEW PL
Mailing Address - Street 2:SUITE U
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1310
Mailing Address - Country:US
Mailing Address - Phone:317-881-1680
Mailing Address - Fax:317-881-0603
Practice Address - Street 1:2801 FAIRVIEW PL
Practice Address - Street 2:SUITE U
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1310
Practice Address - Country:US
Practice Address - Phone:317-881-1680
Practice Address - Fax:317-881-0603
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN12008501B122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124790AMedicaid