Healthcare Provider Details

I. General information

NPI: 1578793923
Provider Name (Legal Business Name): ALEX M BURCIAGA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 CAMP ANTELOPE ROAD
COLEVILLE CA
96107
US

IV. Provider business mailing address

73 CAMP ANTELOPE ROAD
COLEVILLE CA
96107
US

V. Phone/Fax

Practice location:
  • Phone: 530-495-2100
  • Fax: 530-495-2122
Mailing address:
  • Phone: 530-495-2100
  • Fax: 530-495-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10096
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: