Provider Demographics
NPI:1417256090
Name:BURR, JUCKAPONG DIETER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUCKAPONG
Middle Name:DIETER
Last Name:BURR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4388 THOMASSON DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-6767
Mailing Address - Country:US
Mailing Address - Phone:239-417-1553
Mailing Address - Fax:
Practice Address - Street 1:4388 THOMASSON DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-6767
Practice Address - Country:US
Practice Address - Phone:239-417-1553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN192851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice