Provider Demographics
NPI:1558669119
Name:BURCKHARD, JASON (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BURCKHARD
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 1:700 WESTERN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3760
Mailing Address - Country:US
Mailing Address - Phone:701-838-1700
Mailing Address - Fax:
Practice Address - Street 1:700 WESTERN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3760
Practice Address - Country:US
Practice Address - Phone:701-838-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics