Provider Demographics
NPI:1326481995
Name:BURGARDT, GRAYSON JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRAYSON
Middle Name:JOHN
Last Name:BURGARDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6519 E BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-6741
Mailing Address - Country:US
Mailing Address - Phone:620-260-5655
Mailing Address - Fax:
Practice Address - Street 1:13260 N 94TH DR STE 410
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4241
Practice Address - Country:US
Practice Address - Phone:620-260-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28733122300000X
AZD0106921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist