Healthcare Provider Details

I. General information

NPI: 1851513105
Provider Name (Legal Business Name): CHARLES A. HURST D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S 11TH ST
CHESTERTON IN
46304-9381
US

IV. Provider business mailing address

1830 S 11TH ST
CHESTERTON IN
46304-9381
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-1463
  • Fax: 219-926-1169
Mailing address:
  • Phone: 219-926-1463
  • Fax: 219-926-1169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9510
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: