Provider Demographics
NPI:1487061081
Name:BRYAN HALL BURDETTE
Entity type:Organization
Organization Name:BRYAN HALL BURDETTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-245-1061
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
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRYAN HALL BURDETTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty