Provider Demographics
NPI:1477671915
Name:BURLESON, RYAN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:W
Last Name:BURLESON
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 1:1011 W WILLIAMS ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-3979
Mailing Address - Country:US
Mailing Address - Phone:919-367-2875
Mailing Address - Fax:919-367-2855
Practice Address - Street 1:1011 W WILLIAMS ST
Practice Address - Street 2:SUITE 105
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3979
Practice Address - Country:US
Practice Address - Phone:919-367-2875
Practice Address - Fax:919-367-2855
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21556122300000X
WV3700122300000X
NC85331223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH810556546OtherTAX ID
OH2350290Medicaid