Healthcare Provider Details

I. General information

NPI: 1851581979
Provider Name (Legal Business Name): LORI DEBRA HURST DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 FOURTH STREET
STAMFORD CT
06905
US

IV. Provider business mailing address

61 FOURTH STREET
STAMFORD CT
06905
US

V. Phone/Fax

Practice location:
  • Phone: 203-324-3121
  • Fax: 203-348-0969
Mailing address:
  • Phone: 203-324-3121
  • Fax: 203-348-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number007758
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: