Provider Demographics
NPI:1043757081
Name:BURTON FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:BURTON FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-276-1586
Mailing Address - Street 1:1492 MINERAL SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-3130
Mailing Address - Country:US
Mailing Address - Phone:401-353-4880
Mailing Address - Fax:
Practice Address - Street 1:1492 MINERAL SPRING AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-3130
Practice Address - Country:US
Practice Address - Phone:401-353-4880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1684122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty