Provider Demographics
NPI:1710563176
Name:MARTHA HARDAWAY DMD MS PA
Entity Type:Organization
Organization Name:MARTHA HARDAWAY DMD MS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:919-604-1546
Mailing Address - Street 1:176 WIND WALKER CT
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5349
Mailing Address - Country:US
Mailing Address - Phone:919-604-1546
Mailing Address - Fax:
Practice Address - Street 1:247 MOUNT JEFFERSON STATE PARK RD STE 7
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28694-8042
Practice Address - Country:US
Practice Address - Phone:919-604-1546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909845Medicaid