Healthcare Provider Details

I. General information

NPI: 1407903768
Provider Name (Legal Business Name): J. PATRICK HURLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 MONTGOMERY DR
SANTA ROSA CA
95405-5214
US

IV. Provider business mailing address

3775 MONTGOMERY DR
SANTA ROSA CA
95405-5214
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-3791
  • Fax: 707-546-9732
Mailing address:
  • Phone: 707-546-3791
  • Fax: 707-546-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29961
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: