Provider Demographics
NPI:1225309602
Name:J.DIETER BURR, DMD PA
Entity Type:Organization
Organization Name:J.DIETER BURR, DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUCKAPONG
Authorized Official - Middle Name:DIETER
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:352-223-5459
Mailing Address - Street 1:6825 N HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-5012
Mailing Address - Country:US
Mailing Address - Phone:321-631-2111
Mailing Address - Fax:
Practice Address - Street 1:6825 N HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-5012
Practice Address - Country:US
Practice Address - Phone:321-631-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19285261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental