Healthcare Provider Details

I. General information

NPI: 1376592949
Provider Name (Legal Business Name): BURNETT DDS ORAL & FACIAL SURGERY CENTER OF JOPLIN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W 32ND ST
JOPLIN MO
64804
US

IV. Provider business mailing address

620 W 32ND ST
JOPLIN MO
64804
US

V. Phone/Fax

Practice location:
  • Phone: 417-621-0500
  • Fax: 417-781-5809
Mailing address:
  • Phone: 417-621-0500
  • Fax: 417-781-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number010761
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2005005794
License Number StateMO

VIII. Authorized Official

Name: BRADLEY R BURNETT
Title or Position: PRESIDENT
Credential: DDS
Phone: 417-621-0500