Healthcare Provider Details

I. General information

NPI: 1629182498
Provider Name (Legal Business Name): BURTON DENTAL CENTER,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W CLINTON ST SUITE A
DURAND MI
48429
US

IV. Provider business mailing address

103 W CLINTON ST
DURAND MI
48429
US

V. Phone/Fax

Practice location:
  • Phone: 989-288-6165
  • Fax: 989-288-2030
Mailing address:
  • Phone: 989-288-6165
  • Fax: 989-288-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1590520
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13544
License Number State

VIII. Authorized Official

Name: DR. RAJIVA S TIRTHA
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 989-288-6165