Healthcare Provider Details

I. General information

NPI: 1073379202
Provider Name (Legal Business Name): HURST MODERN DENTISTRY AND ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AIRPORT FWY STE D
HURST TX
76053-3965
US

IV. Provider business mailing address

PO BOX 920050
DALLAS TX
75392-0050
US

V. Phone/Fax

Practice location:
  • Phone: 817-532-3358
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALAN LANE
Title or Position: OWNER
Credential:
Phone: 714-845-8500