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General NPI Number Information
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NPI Number | 1861563041
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Entity Type | Organization
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Legal Business Name | LARRY D. BURNSIDE D.D.S.,P.A.
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Dates
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Enumeration Date | 11/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12708 SAN JOSE BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32223-2689
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Country | US
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Telephone | 904-268-0904
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Fax | 904-268-0306
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Provider Business Mailing Address
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Address Line | 711 CREIGHTON RD
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City | ORANGE PARK
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State | FL
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Zip | 32003-7008
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Country | US
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Telephone | 904-264-2759
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Fax | 904-268-0306
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LARRY DAVID BURNSIDE
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Credential | DDS
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Telephone | 904-268-0904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7825
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License Number State | FL
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