Provider Demographics
NPI:1700894771
Name:BURT, RICHARD RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RUSSELL
Last Name:BURT
Suffix:
Gender:M
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0248
Mailing Address - Country:US
Mailing Address - Phone:208-785-2255
Mailing Address - Fax:208-785-2275
Practice Address - Street 1:310 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-0248
Practice Address - Country:US
Practice Address - Phone:208-785-2255
Practice Address - Fax:208-785-2275
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist