Provider Demographics
NPI:1407262389
Name:BURGESS, JANET LAVON (RDHAP, BS)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:LAVON
Last Name:BURGESS
Suffix:
Gender:F
Credentials:RDHAP, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2328 BOUGAINVILLEA TRL
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8965
Mailing Address - Country:US
Mailing Address - Phone:760-332-9253
Mailing Address - Fax:760-370-9235
Practice Address - Street 1:1560 PEPPER DR
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4124
Practice Address - Country:US
Practice Address - Phone:760-332-9253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP 494124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist