Healthcare Provider Details

I. General information

NPI: 1083825962
Provider Name (Legal Business Name): TAD WYLIE BURZYNSKI L.D., R.D.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 NE 4TH ST
BEND OR
97701-4709
US

IV. Provider business mailing address

853 NE 4TH ST.
BEND OR
97701
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-7485
  • Fax: 541-322-0557
Mailing address:
  • Phone: 541-389-7485
  • Fax: 541-322-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO 557317
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: