=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396191045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARLENE BURNETT, RDH, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2016
-----------------------------------------------------
Last Update Date | 05/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 373 E 27TH ST
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-980-1247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1091 NORWAY MAPLE DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-980-1247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL HYGIENIST/OWNER
-----------------------------------------------------
Name | MARLENE THERESE BURNETT
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 970-980-1247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------