Healthcare Provider Details

I. General information

NPI: 1861106817
Provider Name (Legal Business Name): IAN R HURLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 12TH ST NE
ATLANTA GA
30309-3972
US

IV. Provider business mailing address

1030 SASHA LN
ROSWELL GA
30075-3650
US

V. Phone/Fax

Practice location:
  • Phone: 770-525-7712
  • Fax:
Mailing address:
  • Phone: 404-444-2135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN123121
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: