Provider Demographics
NPI:1104826833
Name:BURSON, TERESA A (RDH)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:BURSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:A
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1610 S CHADBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-8510
Mailing Address - Country:US
Mailing Address - Phone:325-658-5339
Mailing Address - Fax:325-659-8534
Practice Address - Street 1:2033 W BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3883
Practice Address - Country:US
Practice Address - Phone:325-947-8577
Practice Address - Fax:325-223-1480
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4569124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist