Healthcare Provider Details

I. General information

NPI: 1427041094
Provider Name (Legal Business Name): ROSIE REDDICK BURROUGHS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N LEE ST
AMERICUS GA
31719-3043
US

IV. Provider business mailing address

PO BOX 1717 715 N LEE ST
AMERICUS GA
31709-1717
US

V. Phone/Fax

Practice location:
  • Phone: 229-928-0545
  • Fax:
Mailing address:
  • Phone: 229-928-0545
  • Fax: 229-928-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9146
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: