Provider Demographics
NPI:1053463109
Name:BURGESS, RICHARD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:BURGESS
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:PO BOX 701047
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78270-1047
Mailing Address - Country:US
Mailing Address - Phone:210-532-5461
Mailing Address - Fax:
Practice Address - Street 1:4721 PECAN VALLEY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1630
Practice Address - Country:US
Practice Address - Phone:210-532-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13310122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13310Medicaid