Provider Demographics
NPI:1497706386
Name:BURT, CHAD S (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:S
Last Name:BURT
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 1:204 E FT UNION BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047
Mailing Address - Country:US
Mailing Address - Phone:801-255-3578
Mailing Address - Fax:801-569-8275
Practice Address - Street 1:204 E FORT UNION BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:801-255-3578
Practice Address - Fax:801-569-8275
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14536599221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice