Provider Demographics
NPI:1053489013
Name:BURNS DENTAL GROUP LLC
Entity Type:Organization
Organization Name:BURNS DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-573-7778
Mailing Address - Street 1:555 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1408
Mailing Address - Country:US
Mailing Address - Phone:541-573-7778
Mailing Address - Fax:541-573-1191
Practice Address - Street 1:555 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1408
Practice Address - Country:US
Practice Address - Phone:541-573-7778
Practice Address - Fax:541-573-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298818Medicaid