Healthcare Provider Details

I. General information

NPI: 1255038675
Provider Name (Legal Business Name): JACOB SYDNEY BURNS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 HARTFORD TPKE
VERNON CT
06066-4407
US

IV. Provider business mailing address

933 HARTFORD TPKE
VERNON CT
06066-4407
US

V. Phone/Fax

Practice location:
  • Phone: 860-870-4410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14037
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: