Healthcare Provider Details

I. General information

NPI: 1003510793
Provider Name (Legal Business Name): KATHERINE BURTS JENNELL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE RENEE BURTS

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 N 25TH ST
RICHMOND VA
23223-6539
US

IV. Provider business mailing address

2809 NORTH AVE
RICHMOND VA
23222-3647
US

V. Phone/Fax

Practice location:
  • Phone: 804-780-0840
  • Fax: 804-329-1206
Mailing address:
  • Phone: 804-944-4504
  • Fax: 804-329-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402003276
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: