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General NPI Number Information
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NPI Number | 1487061081
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Entity Type | Organization
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Legal Business Name | BRYAN HALL BURDETTE
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Dates
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Enumeration Date | 07/15/2014
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Last Update Date | 07/15/2014
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Provider Practice Location Address
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Address Line | 13050 MAGISTERIAL DR SUITE 100
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City | LOUISVILLE
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State | KY
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Zip | 40223-5180
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Country | US
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Telephone | 502-245-1061
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Fax | 502-245-1065
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Provider Business Mailing Address
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Address Line | 13050 MAGISTERIAL DR SUITE 100
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City | LOUISVILLE
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State | KY
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Zip | 40223-5180
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Country | US
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Telephone | 502-245-1061
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Fax | 502-245-1065
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. WANDA JOAN HAYNES
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Credential |
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Telephone | 502-245-1061
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 03223
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License Number State | KY
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