Healthcare Provider Details

I. General information

NPI: 1104869841
Provider Name (Legal Business Name): MICHAEL W HURD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 E HERITAGE PARK ST SUITE 175
MERIDIAN ID
83646
US

IV. Provider business mailing address

13413 W WITTENBURG ST
BOISE ID
83713-0840
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-9645
  • Fax: 208-288-0480
Mailing address:
  • Phone: 208-938-2462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberID03733
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: