Healthcare Provider Details

I. General information

NPI: 1295898906
Provider Name (Legal Business Name): MARK E. HARDWICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 S MAIN ST
ROMEO MI
48065-5129
US

IV. Provider business mailing address

218 S MAIN ST
ROMEO MI
48065-5129
US

V. Phone/Fax

Practice location:
  • Phone: 586-725-6586
  • Fax: 586-752-6221
Mailing address:
  • Phone: 586-725-6586
  • Fax: 586-752-6221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number11564
License Number StateMI

VIII. Authorized Official

Name: DR. MARK EDGAR HARDWICK
Title or Position: GENERAL DENTIST
Credential: D.D.S.
Phone: 586-752-6586