Healthcare Provider Details

I. General information

NPI: 1760432611
Provider Name (Legal Business Name): SEAN P. HART DDS, MSD, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 KOSSUTH ST
LAFAYETTE IN
47905-1560
US

IV. Provider business mailing address

1533 KOSSUTH ST
LAFAYETTE IN
47905-1560
US

V. Phone/Fax

Practice location:
  • Phone: 765-742-8792
  • Fax: 765-742-8792
Mailing address:
  • Phone: 765-742-8792
  • Fax: 765-742-8792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12010263A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: