=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790494771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEREMY W BURGIN, DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2022
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 LEXINGTON RD STE A
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-4466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-762-2355
-----------------------------------------------------
Fax | 575-762-9573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821A LEXINGTON RD
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-4466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-762-2355
-----------------------------------------------------
Fax | 575-762-9573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JANAE D. THORN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-762-2355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------