Provider Demographics
NPI:1720361470
Name:MARTY J. HARDERSON, DDS, PA
Entity Type:Organization
Organization Name:MARTY J. HARDERSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:ALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:479-754-4076
Mailing Address - Street 1:1408 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-9436
Mailing Address - Country:US
Mailing Address - Phone:479-754-4076
Mailing Address - Fax:479-754-4078
Practice Address - Street 1:1408 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-9436
Practice Address - Country:US
Practice Address - Phone:479-754-4076
Practice Address - Fax:479-754-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2952122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117894608Medicaid
AR1598701807OtherTYPE I NPI