Healthcare Provider Details

I. General information

NPI: 1609008648
Provider Name (Legal Business Name): KELLEY ANNE HURSH D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLEY ANNE ELTRINGHAM D.M.D.

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 02/21/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 3690
APO AE
09126-3690
US

IV. Provider business mailing address

UNIT 3690
APO AE
09126-3690
US

V. Phone/Fax

Practice location:
  • Phone: 314-452-8340
  • Fax:
Mailing address:
  • Phone: 314-452-8340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS037967
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS037967
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: