Provider Demographics
NPI:1609970979
Name:HEARN, MATTHEW WILLIAM (DDS MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:HEARN
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 LAKE HURON DR APT 104
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-6746
Mailing Address - Country:US
Mailing Address - Phone:504-220-7344
Mailing Address - Fax:
Practice Address - Street 1:2005 ROOSEVELT RD
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2746
Practice Address - Country:US
Practice Address - Phone:219-531-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060238E1223S0112X
IN01060238A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200511950Medicaid