Provider Demographics
NPI:1538480215
Name:HARDIE DENTISTRY FOR KIDS
Entity Type:Organization
Organization Name:HARDIE DENTISTRY FOR KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARDIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-241-4361
Mailing Address - Street 1:12800 NE 4TH ST
Mailing Address - Street 2:APT 58
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5051
Mailing Address - Country:US
Mailing Address - Phone:360-241-4361
Mailing Address - Fax:360-964-5557
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:360-694-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000087411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty