=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700461548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AHD-CANTON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2021
-----------------------------------------------------
Last Update Date | 03/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 S CLINTON ST STE 335
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21224-5753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-276-4455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 S CHESTER ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21231-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-421-2654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AMANDA LYNN HURLEY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 920-421-2654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------