Provider Demographics
NPI:1083476816
Name:BURGESS, JO DESHA (RDH)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:DESHA
Last Name:BURGESS
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 E CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3906
Mailing Address - Country:US
Mailing Address - Phone:202-714-5843
Mailing Address - Fax:
Practice Address - Street 1:1201 SYCAMORE DR SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-5956
Practice Address - Country:US
Practice Address - Phone:202-745-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHYG2001179124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist