Provider Demographics
NPI:1790922862
Name:BURDETTE, JODIE JUNE (AS)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:JUNE
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BYRON ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-4816
Mailing Address - Country:US
Mailing Address - Phone:269-832-0425
Mailing Address - Fax:
Practice Address - Street 1:26 BYRON ST.
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017
Practice Address - Country:US
Practice Address - Phone:269-832-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902009109124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist