Provider Demographics
NPI:1871758219
Name:BURKHART, JACQUELINE JANE (RDH)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:JANE
Last Name:BURKHART
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JACKI
Other - Middle Name:
Other - Last Name:BURKHART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19765 SE TICKLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BORING
Mailing Address - State:OR
Mailing Address - Zip Code:97009-9516
Mailing Address - Country:US
Mailing Address - Phone:503-866-4520
Mailing Address - Fax:
Practice Address - Street 1:360 NW BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3852
Practice Address - Country:US
Practice Address - Phone:503-667-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4808124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist