Provider Demographics
NPI:1275650764
Name:HARDY, WOLANDA PATRICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WOLANDA
Middle Name:PATRICE
Last Name:HARDY
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 1:10 HUNTINGTON RD
Mailing Address - Street 2:SUITE A2
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3187
Mailing Address - Country:US
Mailing Address - Phone:706-543-7262
Mailing Address - Fax:
Practice Address - Street 1:10 HUNTINGTON RD
Practice Address - Street 2:SUITE A2
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3187
Practice Address - Country:US
Practice Address - Phone:706-543-7262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11903122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000971363AMedicaid
GA13-4220062OtherTAX ID NUMBER