Provider Demographics
NPI:1043658610
Name:BURNESON, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BURNESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 SISKIYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2406
Mailing Address - Country:US
Mailing Address - Phone:541-482-7771
Mailing Address - Fax:541-482-9301
Practice Address - Street 1:1530 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2406
Practice Address - Country:US
Practice Address - Phone:541-482-7771
Practice Address - Fax:541-482-9301
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013016377122300000X
KS61300122300000X
NMDD44611223G0001X
ORD110021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist