MEDICARE: TERESA A BURSON RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	4569	TX

General Provider Information

NPI Number	:	1104826833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA A BURSON RDH

Provider Business Mailing Address
First Line	:	1610 S CHADBOURNE ST
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76903-8510
Country	:	US
Telephone Number	:	325-658-5339
Fax Number	:	325-659-8534

Provider Business Practice Location Address
First Line	:	2033 W BEAUREGARD AVE
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76901-3883
Country	:	US
Telephone Number	:	325-947-8577
Fax Number	:	325-223-1480

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	07/08/2007

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