Provider Demographics
NPI:1063539138
Name:HARDAWAY, OLLIE JR (DDS)
Entity type:Individual
Prefix:DR
First Name:OLLIE
Middle Name:
Last Name:HARDAWAY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 RIALTO ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-6030
Mailing Address - Country:US
Mailing Address - Phone:601-636-0834
Mailing Address - Fax:
Practice Address - Street 1:154 COTTONWOOD STREET
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:662-873-4593
Practice Address - Fax:662-873-4112
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS180178122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660200Medicaid