MEDICARE: LARRY D. BURNSIDE D.D.S.,P.A.

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	7825	FL

General Provider Information

NPI Number	:	1861563041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARRY D. BURNSIDE D.D.S.,P.A.

Provider Business Mailing Address
First Line	:	711 CREIGHTON RD
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32003-7008
Country	:	US
Telephone Number	:	904-264-2759
Fax Number	:	904-268-0306

Provider Business Practice Location Address
First Line	:	12708 SAN JOSE BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-2689
Country	:	US
Telephone Number	:	904-268-0904
Fax Number	:	904-268-0306

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LARRY DAVID BURNSIDE
Credential	:	DDS
Telephone Number	:	904-268-0904

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	08/22/2020

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