Provider Demographics
NPI:1184836744
Name:HARDAWAY, AMELYA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMELYA
Middle Name:R
Last Name:HARDAWAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8551
Mailing Address - Fax:901-260-8590
Practice Address - Street 1:1721 POWDER SPRINGS RD SW STE 103
Practice Address - Street 2:COAST DENTAL - CHEATHAM HILL
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4880
Practice Address - Country:US
Practice Address - Phone:770-293-0605
Practice Address - Fax:770-293-0606
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231261223G0001X
TN90611223G0001X
GADN014519122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516040Medicaid