Provider Demographics
NPI:1679679674
Name:J MARK BURNETT DDS PS
Entity Type:Organization
Organization Name:J MARK BURNETT DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-565-1181
Mailing Address - Street 1:2603 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE I
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4724
Mailing Address - Country:US
Mailing Address - Phone:253-565-1181
Mailing Address - Fax:
Practice Address - Street 1:2603 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE I
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4724
Practice Address - Country:US
Practice Address - Phone:253-565-1181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA43221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5005087Medicaid
WA0019571OtherLABOR & INDUSTRIES