MEDICARE: DR. JOHN BARRY BURGESS DMD

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	1223P0221X	Pediatric Dentistry	3482	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51035759	OTHER	AL	BLUECROSS BLUESHIELD #

General Provider Information

NPI Number	:	1922138072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN BARRY BURGESS DMD

Provider Business Mailing Address
First Line	:	221 RICE MINE RD NE
Second Line	:	SUITE A
City	:	TUSCALOOSA
State	:	AL
Zip	:	35406-2401
Country	:	US
Telephone Number	:	205-758-3341
Fax Number	:	205-758-0846

Provider Business Practice Location Address
First Line	:	221 RICE MINE RD NE
Second Line	:	SUITE A
City	:	TUSCALOOSA
State	:	AL
Zip	:	35406-2401
Country	:	US
Telephone Number	:	205-758-3341
Fax Number	:	205-758-0846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/09/2007

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