Healthcare Provider Details

I. General information

NPI: 1447205901
Provider Name (Legal Business Name): BEVON BURNETT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FAMILY PRACTICE DR
KINGSTON NY
12401-6449
US

IV. Provider business mailing address

1 FAMILY PRACTICE DR
KINGSTON NY
12401-6449
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-6400
  • Fax:
Mailing address:
  • Phone: 845-338-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013697
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number047038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: