Healthcare Provider Details

I. General information

NPI: 1861874463
Provider Name (Legal Business Name): HURT DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 S RANCHO SANTA FE RD
SAN MARCOS CA
92078-2502
US

IV. Provider business mailing address

162 S RANCHO SANTA FE RD
SAN MARCOS CA
92078-2502
US

V. Phone/Fax

Practice location:
  • Phone: 760-734-4311
  • Fax:
Mailing address:
  • Phone: 760-734-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number302F00000X
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number122300000X
License Number StateCA

VIII. Authorized Official

Name: DR. GREGORY ALLEN HURT
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 760-734-4311