Provider Demographics
NPI:1144395765
Name:HURT, GINA LANELLE (DMD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LANELLE
Last Name:HURT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SUITE125-E 1000JOHNSON FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:MARRIETA
Mailing Address - State:GA
Mailing Address - Zip Code:30068
Mailing Address - Country:US
Mailing Address - Phone:770-579-0802
Mailing Address - Fax:770-579-0340
Practice Address - Street 1:SUITE125-E 1000JOHNSON FERRY ROAD
Practice Address - Street 2:SUITE125-E
Practice Address - City:MARRIETA
Practice Address - State:GA
Practice Address - Zip Code:30068
Practice Address - Country:US
Practice Address - Phone:770-579-0802
Practice Address - Fax:770-579-0340
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA011336OtherLICENSE
GA582625375OtherTAX ID