Healthcare Provider Details

I. General information

NPI: 1699841445
Provider Name (Legal Business Name): BURCH GILL CAMERON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 PRINCETON AVE STE A
COLUMBUS GA
31904-9069
US

IV. Provider business mailing address

5605 PRINCETON AVE STE A
COLUMBUS GA
31904-9069
US

V. Phone/Fax

Practice location:
  • Phone: 706-322-2503
  • Fax: 706-322-0240
Mailing address:
  • Phone: 706-322-2503
  • Fax: 706-322-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0008408
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: