Provider Demographics
NPI:1457071714
Name:BURNSED, JILL WALKER (RDH)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:WALKER
Last Name:BURNSED
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 RIVER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-4858
Mailing Address - Country:US
Mailing Address - Phone:904-813-5438
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700-A78
Practice Address - Street 2:
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-497-8076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH009123124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist