Provider Demographics
NPI:1447512728
Name:CARY CHRISTIAN DENTAL CLINIC
Entity type:Organization
Organization Name:CARY CHRISTIAN DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAWAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-529-5196
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:MS
Mailing Address - Zip Code:39054-0057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:154 COTTONWOOD ST.
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:MS
Practice Address - Zip Code:39054
Practice Address - Country:US
Practice Address - Phone:662-873-4593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1801-78292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory