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General NPI Number Information
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NPI Number | 1285123471
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Entity Type | Organization
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Legal Business Name | BURGESS DENTAL
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Dates
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Enumeration Date | 05/03/2018
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Last Update Date | 05/03/2018
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Provider Practice Location Address
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Address Line | 405 CAPITOL STREET THE PARLOR SUITE
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City | CHARLESTON
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State | WV
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Zip | 25301
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Country | US
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Telephone | 304-550-8181
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Fax | 304-346-4842
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Provider Business Mailing Address
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Address Line | 405 CAPITOL STREET THE PARLOR SUITE
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City | CHARLESTON
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State | WV
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Zip | 25301
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Country | US
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Telephone | 304-550-8181
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Fax | 304-346-4842
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN PATRICK BURGESS
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Credential | DDS
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Telephone | 304-346-4820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1038-9730
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License Number State | WV
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