Provider Demographics
NPI:1639144868
Name:HARDY, ROBERT B (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:HARDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 WASHINGTON RD
Mailing Address - Street 2:SUITE M2
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2119
Mailing Address - Country:US
Mailing Address - Phone:706-736-1135
Mailing Address - Fax:706-736-1186
Practice Address - Street 1:1722 WYLDS RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4353
Practice Address - Country:US
Practice Address - Phone:706-736-1135
Practice Address - Fax:706-736-1186
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180179Medicaid
GA003141021AMedicaid
GA793669595AMedicaid