=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407125578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURLINGAME ORTHODONTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2011
-----------------------------------------------------
Last Update Date | 12/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 CHURCH AVE SUITE 2
-----------------------------------------------------
City | BALLSTON SPA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12020-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-885-9473
-----------------------------------------------------
Fax | 518-885-1212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 CHURCH AVE SUITE 2
-----------------------------------------------------
City | BALLSTON SPA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12020-3613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-885-9473
-----------------------------------------------------
Fax | 518-885-1212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHELLE L BURLINGAME
-----------------------------------------------------
Credential | D.M.D.,M.S.
-----------------------------------------------------
Telephone | 518-885-9473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 0548881
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------