Provider Demographics
NPI:1154492593
Name:BURGESS, MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:2103 E WASHINGTON ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4362
Mailing Address - Country:US
Mailing Address - Phone:309-663-6564
Mailing Address - Fax:
Practice Address - Street 1:2103 E WASHINGTON ST STE 4B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4362
Practice Address - Country:US
Practice Address - Phone:309-663-6564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190206671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice