Provider Demographics
NPI:1104980523
Name:BURT, ANDREW MADISON (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MADISON
Last Name:BURT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 PARK ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1780
Mailing Address - Country:US
Mailing Address - Phone:270-781-6161
Mailing Address - Fax:270-781-6129
Practice Address - Street 1:546 PARK ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1780
Practice Address - Country:US
Practice Address - Phone:270-781-6161
Practice Address - Fax:270-781-6129
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72731223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6007273300Medicaid