Healthcare Provider Details

I. General information

NPI: 1265647598
Provider Name (Legal Business Name): CHARLES J BURLISS DMD MSCD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 STILES RD STE 203
SALEM NH
03079-2881
US

IV. Provider business mailing address

12 STILES RD STE 203
SALEM NH
03079-2881
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number2529
License Number StateNH

VIII. Authorized Official

Name: DR. CHARLES J BURLISS
Title or Position: PRESIDENT
Credential: DMD MSCD
Phone: 603-898-1961