Healthcare Provider Details

I. General information

NPI: 1477522266
Provider Name (Legal Business Name): RICK LEE HURST DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 RUSSELL BLVD
NACOGDOCHES TX
75965-1244
US

IV. Provider business mailing address

508 RUSSELL BLVD
NACOGDOCHES TX
75965-1244
US

V. Phone/Fax

Practice location:
  • Phone: 936-569-1111
  • Fax:
Mailing address:
  • Phone: 936-569-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11092
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: