=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629085204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS J HARDY D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 766 STILLWATER AVE
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-3616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-942-1442
-----------------------------------------------------
Fax | 207-942-1832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 920
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04402-0920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-942-1442
-----------------------------------------------------
Fax | 207-942-1832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3248
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------