Provider Demographics
NPI:1043378870
Name:BURCKHALTER, L JARRETTE IV (DMD)
Entity type:Individual
Prefix:DR
First Name:L
Middle Name:JARRETTE
Last Name:BURCKHALTER
Suffix:IV
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 1:1643 CAROLINA AVENUE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115
Mailing Address - Country:US
Mailing Address - Phone:803-534-7525
Mailing Address - Fax:803-534-7526
Practice Address - Street 1:1643 CAROLINA AVENUE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115
Practice Address - Country:US
Practice Address - Phone:803-534-7525
Practice Address - Fax:803-534-7526
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC20951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC341798Medicaid