Provider Demographics
NPI:1376685859
Name:BURGESS,JR, W L (DDS)
Entity Type:Individual
Prefix:
First Name:W
Middle Name:L
Last Name:BURGESS,JR
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 1:8159 WALNUT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7270
Mailing Address - Country:US
Mailing Address - Phone:901-756-8111
Mailing Address - Fax:901-756-8171
Practice Address - Street 1:8159 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7270
Practice Address - Country:US
Practice Address - Phone:901-756-8111
Practice Address - Fax:901-756-8171
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice