Provider Demographics
NPI:1346567112
Name:BURBANK, JAROM R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAROM
Middle Name:R
Last Name:BURBANK
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 1:652 HAMILTON RD
Mailing Address - Street 2:USA DENTAL ACTIVITY
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-3905
Mailing Address - Fax:580-442-4002
Practice Address - Street 1:652 HAMILTON RD
Practice Address - Street 2:USA DENTAL ACTIVITY
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:580-442-4002
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7485620-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist