Healthcare Provider Details

I. General information

NPI: 1164512653
Provider Name (Legal Business Name): BRENT HURST DDSMSPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 CARLSBAD VILLAGE DR STE P
CARLSBAD CA
92008-1958
US

IV. Provider business mailing address

1207 CARLSBAD VILLAGE DR. #P
CARLSBAD CA
92008
US

V. Phone/Fax

Practice location:
  • Phone: 760-729-8101
  • Fax: 760-729-9696
Mailing address:
  • Phone: 760-729-8101
  • Fax: 760-729-9696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number44486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: