Healthcare Provider Details

I. General information

NPI: 1346334109
Provider Name (Legal Business Name): EDWIN SCHAUB HURST D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 200 N STE B1
LOGAN UT
84321-4036
US

IV. Provider business mailing address

150 E 200 N STE B1
LOGAN UT
84321-4036
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-4533
  • Fax: 435-752-4586
Mailing address:
  • Phone: 435-752-4533
  • Fax: 435-752-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number142135
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: