Provider Demographics
NPI:1023220365
Name:CLYDE WALCEY BURRIS, III, D.D.S., P.C.
Entity Type:Organization
Organization Name:CLYDE WALCEY BURRIS, III, D.D.S., P.C.
Other - Org Name:C. WALCEY BURRIS, III, D.D.S., P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:WALCEY
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:276-956-9000
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-0483
Mailing Address - Country:US
Mailing Address - Phone:276-956-9000
Mailing Address - Fax:276-956-9002
Practice Address - Street 1:4950 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3390
Practice Address - Country:US
Practice Address - Phone:276-956-9000
Practice Address - Fax:276-956-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086491223G0001X
NC66571223G0001X
SC33931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty