Provider Demographics
NPI:1902423239
Name:HART FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:HART FAMILY DENTISTRY PLLC
Other - Org Name:HART LAKE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:KURTIS
Authorized Official - Last Name:GILLISH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-873-4025
Mailing Address - Street 1:110 S DRYDEN ST
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-1105
Mailing Address - Country:US
Mailing Address - Phone:231-873-4025
Mailing Address - Fax:
Practice Address - Street 1:110 S DRYDEN ST
Practice Address - Street 2:
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1105
Practice Address - Country:US
Practice Address - Phone:231-873-4025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-02
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty