Healthcare Provider Details

I. General information

NPI: 1104980523
Provider Name (Legal Business Name): ANDREW MADISON BURT D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 PARK ST SUITE 400
BOWLING GREEN KY
42101-1780
US

IV. Provider business mailing address

546 PARK ST SUITE 400
BOWLING GREEN KY
42101-1780
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-6161
  • Fax: 270-781-6129
Mailing address:
  • Phone: 270-781-6161
  • Fax: 270-781-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7273
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7273
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: