Provider Demographics
NPI:1407143407
Name:BURGE, JENNIFER MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:BURGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4901
Mailing Address - Country:US
Mailing Address - Phone:309-454-1425
Mailing Address - Fax:309-862-3933
Practice Address - Street 1:305 S LINDEN ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-4901
Practice Address - Country:US
Practice Address - Phone:309-454-1425
Practice Address - Fax:309-862-3933
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190286891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice