Provider Demographics
NPI:1114130762
Name:BURGESS, PHILIP ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALAN
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 1:5731 LA JOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7302
Mailing Address - Country:US
Mailing Address - Phone:858-459-0229
Mailing Address - Fax:858-459-8072
Practice Address - Street 1:5731 LA JOLLA BLVD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7302
Practice Address - Country:US
Practice Address - Phone:858-459-0229
Practice Address - Fax:858-459-8072
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22582122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
573392OtherUNITED CONCORDIA PROVIDER