Provider Demographics
NPI:1275628729
Name:BURLISS, CHARLES J (DMD,MSCD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:BURLISS
Suffix:
Gender:M
Credentials:DMD,MSCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 STILES RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079
Mailing Address - Country:US
Mailing Address - Phone:603-898-1961
Mailing Address - Fax:603-898-4508
Practice Address - Street 1:12 STILES RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079
Practice Address - Country:US
Practice Address - Phone:603-898-1961
Practice Address - Fax:603-898-4508
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH25291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics