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General NPI Number Information
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NPI Number | 1396198446
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Entity Type | Organization
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Legal Business Name | BURRY ENDODONTICS LLC
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Dates
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Enumeration Date | 07/13/2016
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Last Update Date | 07/13/2016
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Provider Practice Location Address
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Address Line | 205 W FAIRHAVEN AVE STE A
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City | BURLINGTON
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State | WA
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Zip | 98233-1062
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Country | US
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Telephone | 360-757-3636
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Fax |
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Provider Business Mailing Address
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Address Line | 205 W FAIRHAVEN AVE STE A
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City | BURLINGTON
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State | WA
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Zip | 98233-1062
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Country | US
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Telephone | 360-757-3636
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. JACOB CHARLES BURRY
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Credential | DDS, MS.
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Telephone | 208-949-1351
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 60389753
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License Number State | WA
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