Provider Demographics
NPI:1083825962
Name:BURZYNSKI, TAD WYLIE (LD, RDH)
Entity Type:Individual
Prefix:MR
First Name:TAD
Middle Name:WYLIE
Last Name:BURZYNSKI
Suffix:
Gender:M
Credentials:LD, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 NE 4TH ST.
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-389-7485
Mailing Address - Fax:541-322-0557
Practice Address - Street 1:853 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4709
Practice Address - Country:US
Practice Address - Phone:541-389-7485
Practice Address - Fax:541-322-0557
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO 557317122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist