Provider Demographics
NPI:1659808822
Name:BURNS, NATHANIEL H
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:H
Last Name:BURNS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 W MORELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2432
Mailing Address - Country:US
Mailing Address - Phone:262-542-4827
Mailing Address - Fax:
Practice Address - Street 1:713 W MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2432
Practice Address - Country:US
Practice Address - Phone:262-542-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001544-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist