Provider Demographics
NPI:1376150482
Name:HURST CANDID WISCONSIN, SERVICE CORPORATION
Entity Type:Organization
Organization Name:HURST CANDID WISCONSIN, SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-481-7631
Mailing Address - Street 1:345 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2996
Mailing Address - Country:US
Mailing Address - Phone:860-481-7631
Mailing Address - Fax:
Practice Address - Street 1:345 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2996
Practice Address - Country:US
Practice Address - Phone:860-481-7631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty