Provider Demographics
NPI:1104046051
Name:BURNS, CHARLES GREGORY (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GREGORY
Last Name:BURNS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1411
Mailing Address - Country:US
Mailing Address - Phone:478-742-1206
Mailing Address - Fax:478-742-7311
Practice Address - Street 1:540 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1411
Practice Address - Country:US
Practice Address - Phone:478-742-1206
Practice Address - Fax:478-742-7311
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice