Healthcare Provider Details

I. General information

NPI: 1275628729
Provider Name (Legal Business Name): CHARLES J BURLISS DMD,MSCD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 STILES RD SUITE 203
SALEM NH
03079
US

IV. Provider business mailing address

12 STILES RD SUITE 203
SALEM NH
03079
US

V. Phone/Fax

Practice location:
  • Phone: 603-898-1961
  • Fax: 603-898-4508
Mailing address:
  • Phone: 603-898-1961
  • Fax: 603-898-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2529
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: