Provider Demographics
NPI:1780910604
Name:HART FAMILY DENTAL
Entity type:Organization
Organization Name:HART FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CICI
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANTHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-329-6713
Mailing Address - Street 1:56728 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2941
Mailing Address - Country:US
Mailing Address - Phone:760-365-6595
Mailing Address - Fax:
Practice Address - Street 1:56728 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2941
Practice Address - Country:US
Practice Address - Phone:760-365-6595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HART FAMILY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty