Provider Demographics
NPI:1942207238
Name:BURDETTE, BRYAN HALL (DMD, MS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:HALL
Last Name:BURDETTE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13050 MAGISTERIAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5180
Mailing Address - Country:US
Mailing Address - Phone:502-245-1061
Mailing Address - Fax:502-245-1065
Practice Address - Street 1:13050 MAGISTERIAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5180
Practice Address - Country:US
Practice Address - Phone:502-245-1061
Practice Address - Fax:502-245-1065
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4567122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000050182OtherBC/BS
1178384Medicare UPIN
KY1822901Medicare ID - Type Unspecified