Provider Demographics
NPI:1558506113
Name:HARDIN, DENNIS RALPH (GENERAL DENTIST)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RALPH
Last Name:HARDIN
Suffix:
Gender:M
Credentials:GENERAL DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5648
Mailing Address - Country:US
Mailing Address - Phone:800-373-5400
Mailing Address - Fax:
Practice Address - Street 1:222 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5648
Practice Address - Country:US
Practice Address - Phone:800-373-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20757Medicaid