Basic Information
| Provider Information | |||||||||
| NPI: | 1548257686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W. ENT AVE | ||||||||
| Address2: | ATTN: 21 DS/SGGD- DENTAL SQUADRON | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561333 | ||||||||
| FaxNumber: | 7195561331 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W. ENT AVE | ||||||||
| Address2: | ATTN: 21 DS/SGGD- DENTAL SQUADRON | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561333 | ||||||||
| FaxNumber: | 7195561331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | 18596 | TX | N | Dental Providers | Dentist | Periodontics | 1223P0300X | 8554 | IN | Y | Dental Providers | Dentist | Periodontics |
No ID Information.