MEDICARE: HART DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1164828059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HART DDS PC

Provider Business Mailing Address
First Line	:	4531 PHILADELPHIA ST
Second Line	:	UNIT 107
City	:	CHINO
State	:	CA
Zip	:	91710-2262
Country	:	US
Telephone Number	:	909-902-9100
Fax Number	:	909-902-9112

Provider Business Practice Location Address
First Line	:	4531 PHILADELPHIA ST
Second Line	:	UNIT 107
City	:	CHINO
State	:	CA
Zip	:	91710-2262
Country	:	US
Telephone Number	:	909-902-9100
Fax Number	:	909-902-9112

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MARNIE CHACON
Credential	:
Telephone Number	:	909-902-9100

Provider Enumeration Date	:	11/05/2014
Last Update Date	:	01/27/2016

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