MEDICARE: DR. KELLY PATER HEARN DDS

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	1223G0001X	General Practice Dentistry	2901019815	MI

General Provider Information

NPI Number	:	1811156748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY PATER HEARN DDS

Provider Business Mailing Address
First Line	:	1220 E NAPIER AVE
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-3900
Country	:	US
Telephone Number	:	269-925-2113
Fax Number	:	269-925-2191

Provider Business Practice Location Address
First Line	:	1220 E NAPIER AVE
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-3900
Country	:	US
Telephone Number	:	269-925-2113
Fax Number	:	269-925-2191

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	09/14/2010

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