Provider Demographics
NPI:1164648267
Name:BURGESS, LARRY WINSTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WINSTON
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 1:129 S MILL TRACE DR
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-3845
Mailing Address - Country:US
Mailing Address - Phone:281-362-0432
Mailing Address - Fax:
Practice Address - Street 1:10700 KUYKENDAHL RD STE E
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381
Practice Address - Country:US
Practice Address - Phone:281-367-5900
Practice Address - Fax:281-292-4370
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX161311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice