=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942579172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW M BURT DMD PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2011
-----------------------------------------------------
Last Update Date | 12/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 546 PARK ST STE 400
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-1780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-781-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 546 PARK ST STE 400
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-1780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-781-6161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / DR.
-----------------------------------------------------
Name | DR. ANDREW MADISON BURT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 270-781-6161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7273
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------