Provider Demographics
NPI:1033243027
Name:BURT, CHARLES RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:BURT
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 1:270 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-2909
Mailing Address - Country:US
Mailing Address - Phone:540-483-1246
Mailing Address - Fax:
Practice Address - Street 1:1175 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1248
Practice Address - Country:US
Practice Address - Phone:540-483-7577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA46071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice