Provider Demographics
NPI:1093891533
Name:HARDIE, WILLIE M (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:M
Last Name:HARDIE
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 1:925 NE 136TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-0896
Mailing Address - Country:US
Mailing Address - Phone:360-694-5559
Mailing Address - Fax:360-891-0000
Practice Address - Street 1:925 NE 136TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-0896
Practice Address - Country:US
Practice Address - Phone:360-694-5559
Practice Address - Fax:360-891-0000
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000087411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007980OtherGROUP MEDICAID
WA1002369Medicaid