Provider Demographics
NPI:1851528673
Name:BURT, THERESA LANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:LANE
Last Name:BURT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23867 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-2301
Mailing Address - Country:US
Mailing Address - Phone:248-943-6861
Mailing Address - Fax:
Practice Address - Street 1:23867 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-2301
Practice Address - Country:US
Practice Address - Phone:248-943-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist