Provider Demographics
NPI:1164582524
Name:BURGESS, JOHN OLAN (DDS MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:OLAN
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 7TH AVE S SDB BOX 58 1
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294
Mailing Address - Country:US
Mailing Address - Phone:205-934-2340
Mailing Address - Fax:205-934-7899
Practice Address - Street 1:1919 7TH AVE S SDB BOX 58 1
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294
Practice Address - Country:US
Practice Address - Phone:205-934-2340
Practice Address - Fax:205-934-7899
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice