Provider Demographics
NPI:1396829693
Name:BEAUFORT ORTHODONTICS LLC
Entity Type:Organization
Organization Name:BEAUFORT ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:A
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-986-9339
Mailing Address - Street 1:960 RIBAUT RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5431
Mailing Address - Country:US
Mailing Address - Phone:843-986-9339
Mailing Address - Fax:843-524-4468
Practice Address - Street 1:960 RIBAUT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5431
Practice Address - Country:US
Practice Address - Phone:843-986-9339
Practice Address - Fax:843-524-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36281223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty