Healthcare Provider Details

I. General information

NPI: 1144395765
Provider Name (Legal Business Name): GINA LANELLE HURT D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUITE125-E 1000JOHNSON FERRY ROAD SUITE125-E
MARRIETA GA
30068
US

IV. Provider business mailing address

SUITE125-E 1000JOHNSON FERRY ROAD
MARRIETA GA
30068
US

V. Phone/Fax

Practice location:
  • Phone: 770-579-0802
  • Fax: 770-579-0340
Mailing address:
  • Phone: 770-579-0802
  • Fax: 770-579-0340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number011336
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: