Provider Demographics
NPI:1922123942
Name:HALL, BURNETTA LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BURNETTA
Middle Name:LYNN
Last Name:HALL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:HAROLD
Mailing Address - State:KY
Mailing Address - Zip Code:41635-0448
Mailing Address - Country:US
Mailing Address - Phone:606-478-4777
Mailing Address - Fax:
Practice Address - Street 1:88 CHURCH RD
Practice Address - Street 2:
Practice Address - City:HAROLD
Practice Address - State:KY
Practice Address - Zip Code:41635-9016
Practice Address - Country:US
Practice Address - Phone:606-478-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60057429Medicaid