MEDICARE: J MARK BURNETT DDS PS

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	1223G0001X	General Practice Dentistry	4322	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0019571	OTHER	WA	LABOR & INDUSTRIES

General Provider Information

NPI Number	:	1679679674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J MARK BURNETT DDS PS

Provider Business Mailing Address
First Line	:	2603 BRIDGEPORT WAY W
Second Line	:	SUITE I
City	:	UNIVERSITY PLACE
State	:	WA
Zip	:	98466-4724
Country	:	US
Telephone Number	:	253-565-1181
Fax Number	:

Provider Business Practice Location Address
First Line	:	2603 BRIDGEPORT WAY W
Second Line	:	SUITE I
City	:	UNIVERSITY PLACE
State	:	WA
Zip	:	98466-4724
Country	:	US
Telephone Number	:	253-565-1181
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	J MARK BURNETT
Credential	:	DDS
Telephone Number	:	253-565-1181

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	08/22/2020

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