Healthcare Provider Details

I. General information

NPI: 1942302294
Provider Name (Legal Business Name): BENJAMIN GRAY BURRIS DDS, MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 GOOD HOMES ROAD
ORLANDO FL
32818
US

IV. Provider business mailing address

837 GOOD HOMES ROAD
ORLANDO FL
32818
US

V. Phone/Fax

Practice location:
  • Phone: 870-926-5321
  • Fax:
Mailing address:
  • Phone: 870-926-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberS3-222C
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3465
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number101237
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number109030995
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9869
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6020
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2009033293
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number200
License Number StateOK
# 9
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number58955
License Number StateNY
# 10
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9071
License Number StateTN
# 11
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number25757
License Number StateTX
# 12
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number10186273-9921
License Number StateUT
# 13
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number104
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: