=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588654206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY D HURST DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 W WASHINGTON AVE SUITE 201
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-784-3009
-----------------------------------------------------
Fax | 517-784-4544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1547 RIDGE RD
-----------------------------------------------------
City | CHELSEA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48118-9793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-475-2180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 012806
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------