Provider Demographics
NPI:1134275597
Name:HART, TIMOTHY OTTO (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:OTTO
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 1:1720 E LAKE BLUFF BLVD
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1517
Mailing Address - Country:US
Mailing Address - Phone:414-962-1800
Mailing Address - Fax:414-962-2302
Practice Address - Street 1:1720 E LAKE BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1517
Practice Address - Country:US
Practice Address - Phone:414-962-1800
Practice Address - Fax:414-962-2302
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1896G1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics