Provider Demographics
NPI:1124187034
Name:BURNS, NICHOLAS J (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:BURNS
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 1:2126 E 1730 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-7505
Mailing Address - Country:US
Mailing Address - Phone:815-432-3889
Mailing Address - Fax:815-432-6135
Practice Address - Street 1:108 E OAK ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1344
Practice Address - Country:US
Practice Address - Phone:815-432-6131
Practice Address - Fax:815-432-6135
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice