MEDICARE: BURTON FAMILY DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1684	RI

General Provider Information

NPI Number	:	1043757081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURTON FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	1492 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-3130
Country	:	US
Telephone Number	:	401-353-4880
Fax Number	:

Provider Business Practice Location Address
First Line	:	1492 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-3130
Country	:	US
Telephone Number	:	401-353-4880
Fax Number	:

Authorized Official
Title or Position	:	CONSULTANT
Name	:	DANIELLE CASARELLA
Credential	:
Telephone Number	:	860-276-1586

Provider Enumeration Date	:	01/29/2017
Last Update Date	:	01/29/2017

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