Provider Demographics
NPI:1104342286
Name:HARDISTY, GRANT MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:MICHAEL
Last Name:HARDISTY
Suffix:
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 1:1377 ESTUARY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-5267
Mailing Address - Country:US
Mailing Address - Phone:317-937-2661
Mailing Address - Fax:
Practice Address - Street 1:924 WILLIAMS PARK DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-6713
Practice Address - Country:US
Practice Address - Phone:812-279-2022
Practice Address - Fax:812-277-9915
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2017-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012807A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist