Provider Demographics
NPI:1538585617
Name:MATTHEW HEARN
Entity type:Organization
Organization Name:MATTHEW HEARN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HEARN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MD
Authorized Official - Phone:504-220-7344
Mailing Address - Street 1:2009 ROOSEVELT RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3765
Mailing Address - Country:US
Mailing Address - Phone:504-220-7344
Mailing Address - Fax:
Practice Address - Street 1:2009 ROOSEVELT RD
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3765
Practice Address - Country:US
Practice Address - Phone:504-220-7344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010718A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental