Provider Demographics
NPI:1720291560
Name:EDGREN, BURDETT RUSSELL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BURDETT
Middle Name:RUSSELL
Last Name:EDGREN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
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Mailing Address - Street 1:3400 W 16TH ST
Mailing Address - Street 2:BLDG 4-V
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6862
Mailing Address - Country:US
Mailing Address - Phone:970-356-5900
Mailing Address - Fax:970-356-2418
Practice Address - Street 1:3400 W 16TH ST
Practice Address - Street 2:BLDG 4-V
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6862
Practice Address - Country:US
Practice Address - Phone:970-356-5900
Practice Address - Fax:970-356-2418
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics