Provider Demographics
NPI:1417570250
Name:BURGOS, JULISSA E (DMD)
Entity Type:Individual
Prefix:DR
First Name:JULISSA
Middle Name:E
Last Name:BURGOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 MAIN ST APT 522
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-8168
Mailing Address - Country:US
Mailing Address - Phone:561-806-9766
Mailing Address - Fax:
Practice Address - Street 1:5046 TURNEY RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2503
Practice Address - Country:US
Practice Address - Phone:216-662-7799
Practice Address - Fax:216-441-4908
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014178661223G0001X
OH30.026216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice