Healthcare Provider Details

I. General information

NPI: 1164749396
Provider Name (Legal Business Name): REPUBLIC DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 N. PORTLAND ST.
REPUBLIC WA
99166-0978
US

IV. Provider business mailing address

PO BOX 978
REPUBLIC WA
99166-0978
US

V. Phone/Fax

Practice location:
  • Phone: 509-775-3169
  • Fax: 509-775-2272
Mailing address:
  • Phone: 509-775-3169
  • Fax: 509-775-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5070
License Number StateWA

VIII. Authorized Official

Name: DR. ROBERT W. HARDWICK JR.
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 509-775-3169