Healthcare Provider Details

I. General information

NPI: 1790758993
Provider Name (Legal Business Name): JASON LAWRENCE BURAK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 DODGE ST PERIONORTH
BEVERLY MA
01915-1786
US

IV. Provider business mailing address

56 DODGE ST PERIONORTH
BEVERLY MA
01915-1786
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-7666
  • Fax: 978-921-1714
Mailing address:
  • Phone: 978-922-7666
  • Fax: 978-921-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20797
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: