Healthcare Provider Details

I. General information

NPI: 1881672673
Provider Name (Legal Business Name): THOMAS J BURDO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 4 MILE RD NW
GRAND RAPIDS MI
49544-7397
US

IV. Provider business mailing address

1100 4 MILE RD NW
GRAND RAPIDS MI
49544-7397
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-6377
  • Fax:
Mailing address:
  • Phone: 616-784-6377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14913
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14913
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: