Provider Demographics
NPI:1902900178
Name:HURT, MICHAEL TERRY (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TERRY
Last Name:HURT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4270 PLAINFIELD NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1603
Mailing Address - Country:US
Mailing Address - Phone:616-361-9497
Mailing Address - Fax:
Practice Address - Street 1:4270 PLAINFIELD NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1603
Practice Address - Country:US
Practice Address - Phone:616-361-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010084801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice