Provider Demographics
NPI:1114193687
Name:BURGESS, WALTER H (DMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:H
Last Name:BURGESS
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 1:104 E GUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467-1604
Mailing Address - Country:US
Mailing Address - Phone:334-493-3501
Mailing Address - Fax:334-493-3502
Practice Address - Street 1:104 E GUNTER AVE
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-1604
Practice Address - Country:US
Practice Address - Phone:334-493-3501
Practice Address - Fax:334-493-3502
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist