Provider Demographics
NPI:1003020132
Name:BURSICH, THOMAS RICHARD (DDS, RPH)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICHARD
Last Name:BURSICH
Suffix:
Gender:M
Credentials:DDS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 WOLF RUN CT
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-5513
Mailing Address - Country:US
Mailing Address - Phone:814-835-3830
Mailing Address - Fax:814-476-0078
Practice Address - Street 1:9008 MAIN ST
Practice Address - Street 2:
Practice Address - City:MC KEAN
Practice Address - State:PA
Practice Address - Zip Code:16426-1454
Practice Address - Country:US
Practice Address - Phone:814-476-7714
Practice Address - Fax:814-476-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023805L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice