Healthcare Provider Details

I. General information

NPI: 1255307310
Provider Name (Legal Business Name): JEFFERY MARK HURST DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 KIPLING ST
LAKEWOOD CO
80215-1584
US

IV. Provider business mailing address

1927 DENVER WEST CT APT 1934
LAKEWOOD CO
80401-0948
US

V. Phone/Fax

Practice location:
  • Phone: 303-238-5812
  • Fax: 303-238-0343
Mailing address:
  • Phone: 303-277-9975
  • Fax: 303-238-0343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104884
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: