Healthcare Provider Details

I. General information

NPI: 1710563176
Provider Name (Legal Business Name): MARTHA HARDAWAY DMD MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 MOUNT JEFFERSON STATE PARK RD STE 7
WEST JEFFERSON NC
28694-8042
US

IV. Provider business mailing address

176 WIND WALKER CT
BOONE NC
28607-5349
US

V. Phone/Fax

Practice location:
  • Phone: 919-604-1546
  • Fax:
Mailing address:
  • Phone: 919-604-1546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARTHA HARDAWAY
Title or Position: PRESIDENT
Credential: DMD MS
Phone: 919-604-1546