Healthcare Provider Details

I. General information

NPI: 1215466826
Provider Name (Legal Business Name): AMANDA LYNN HURLEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. AMANDA LYNN GLASHEEN

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CLINTON ST
BALTIMORE MD
21224-5730
US

IV. Provider business mailing address

246 S CHESTER ST
BALTIMORE MD
21231-2625
US

V. Phone/Fax

Practice location:
  • Phone: 410-276-4455
  • Fax:
Mailing address:
  • Phone: 920-421-2654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1001593
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16436
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1001593
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number16436
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: