Provider Demographics
NPI:1750555033
Name:BURT & JACKSON DMD PLLC BLUEGRASS ORAL HEALTH CENTER OF MORGANTOWN
Entity type:Organization
Organization Name:BURT & JACKSON DMD PLLC BLUEGRASS ORAL HEALTH CENTER OF MORGANTOWN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:MADISON
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-526-3346
Mailing Address - Street 1:304 WEST OHIO ST.
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261
Mailing Address - Country:US
Mailing Address - Phone:270-526-3346
Mailing Address - Fax:
Practice Address - Street 1:304 WEST OHIO ST.
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261
Practice Address - Country:US
Practice Address - Phone:270-526-3346
Practice Address - Fax:270-781-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicaid