=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710974795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN W BURTON D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2005
-----------------------------------------------------
Last Update Date | 05/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2250 N REED STATION RD SUITE 201
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62901-8101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-519-9363
-----------------------------------------------------
Fax | 618-519-9364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2250 N REED STATION RD SUITE 201
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62901-8101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-519-9363
-----------------------------------------------------
Fax | 618-519-9364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019-026124
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 021-002074
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------