Provider Demographics
NPI:1003817677
Name:DORNBURG, TERRY E (DDS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:E
Last Name:DORNBURG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:124 MILLER ST
Mailing Address - City:GRANTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21536-0359
Mailing Address - Country:US
Mailing Address - Phone:301-895-5955
Mailing Address - Fax:301-746-8676
Practice Address - Street 1:124 MILLER ST
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536
Practice Address - Country:US
Practice Address - Phone:301-895-5955
Practice Address - Fax:301-746-8676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD 6942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist