MEDICARE: MARLENE THERESE BURNETT RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	200865	CO

General Provider Information

NPI Number	:	1578724688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLENE THERESE BURNETT RDH

Provider Business Mailing Address
First Line	:	1091 NORWAY MAPLE DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-5608
Country	:	US
Telephone Number	:	970-980-1247
Fax Number	:

Provider Business Practice Location Address
First Line	:	373 E 27TH ST
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-3203
Country	:	US
Telephone Number	:	970-980-1247
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2008
Last Update Date	:	05/12/2016

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