Provider Demographics
NPI:1124507363
Name:HARDY, JESSICA AMANDA (DMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AMANDA
Last Name:HARDY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1588 N COAL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-7615
Mailing Address - Country:US
Mailing Address - Phone:435-820-6666
Mailing Address - Fax:
Practice Address - Street 1:1588 N. COAL CREEK RD.
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-8450
Practice Address - Country:US
Practice Address - Phone:435-820-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD010048OtherARIZONA STATE BOARD OF DENTAL EXAMINERS