Provider Demographics
NPI:1710974795
Name:BURTON, JONATHAN W (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:BURTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2250 N REED STATION RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-8101
Mailing Address - Country:US
Mailing Address - Phone:618-519-9363
Mailing Address - Fax:618-519-9364
Practice Address - Street 1:2250 N REED STATION RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-8101
Practice Address - Country:US
Practice Address - Phone:618-519-9363
Practice Address - Fax:618-519-9364
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-026124122300000X
IL021-0020741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist