Healthcare Provider Details

I. General information

NPI: 1255736278
Provider Name (Legal Business Name): CHARLES DANIEL HURLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14377 WOODLAKE DR STE 211
CHESTERFIELD MO
63017-5735
US

IV. Provider business mailing address

14377 WOODLAKE DR SUITE 211
CHESTERFIELD MO
63017-5735
US

V. Phone/Fax

Practice location:
  • Phone: 314-576-1777
  • Fax: 314-576-4584
Mailing address:
  • Phone: 314-576-1777
  • Fax: 314-576-4584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2014015546
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: