Healthcare Provider Details

I. General information

NPI: 1366533887
Provider Name (Legal Business Name): STEPHANIE LYNN BURROUGHS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 W MAIN ST
AVON NY
14414-1136
US

IV. Provider business mailing address

74 W MAIN ST
AVON NY
14414-1136
US

V. Phone/Fax

Practice location:
  • Phone: 585-226-3113
  • Fax:
Mailing address:
  • Phone: 585-226-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number050216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: