Provider Demographics
NPI:1285623348
Name:HART, GERALD ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ALLEN
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0609
Mailing Address - Country:US
Mailing Address - Phone:608-742-3272
Mailing Address - Fax:608-742-0523
Practice Address - Street 1:225 GUNDERSON DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3430
Practice Address - Country:US
Practice Address - Phone:608-742-3272
Practice Address - Fax:608-742-0523
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3329122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist