Provider Demographics
NPI:1003907122
Name:BURGESS, DOUGLAS WILFORD (DDS PA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILFORD
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 MADISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-625-7550
Mailing Address - Fax:507-388-3353
Practice Address - Street 1:730 MADISON AVENUE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-7550
Practice Address - Fax:507-388-3353
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist