Healthcare Provider Details

I. General information

NPI: 1730174590
Provider Name (Legal Business Name): JEFFREY R BURROUGHS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 W 119TH ST STE 215
OVERLAND PARK KS
66209-3724
US

IV. Provider business mailing address

5525 W 119TH ST STE 215
OVERLAND PARK KS
66209-3724
US

V. Phone/Fax

Practice location:
  • Phone: 913-258-5696
  • Fax: 913-258-5697
Mailing address:
  • Phone: 913-258-5696
  • Fax: 913-258-5697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019-026760
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7054
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number61135
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: