Provider Demographics
NPI:1164749396
Name:REPUBLIC DENTAL CLINIC
Entity Type:Organization
Organization Name:REPUBLIC DENTAL CLINIC
Other - Org Name:ROB HARDWICK, D.D.S.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARDWICK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-775-3169
Mailing Address - Street 1:PO BOX 978
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-0978
Mailing Address - Country:US
Mailing Address - Phone:509-775-3169
Mailing Address - Fax:509-775-2272
Practice Address - Street 1:194 N. PORTLAND ST.
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-0978
Practice Address - Country:US
Practice Address - Phone:509-775-3169
Practice Address - Fax:509-775-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5027230Medicaid