Provider Demographics
NPI:1871887323
Name:BURBANK, JONATHAN (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BURBANK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CENTRE SALCELLE BLVD
Mailing Address - Street 2:SUITE 705
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-6352
Mailing Address - Country:US
Mailing Address - Phone:337-451-4636
Mailing Address - Fax:
Practice Address - Street 1:107 CENTRE SALCELLE BLVD
Practice Address - Street 2:SUITE 705
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-6352
Practice Address - Country:US
Practice Address - Phone:337-451-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA61801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice