Provider Demographics
NPI:1518174614
Name:BURGOYNE, COREY C (DMD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:C
Last Name:BURGOYNE
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 1:54 S MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2333
Mailing Address - Country:US
Mailing Address - Phone:540-886-2956
Mailing Address - Fax:540-213-8748
Practice Address - Street 1:54 S MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2333
Practice Address - Country:US
Practice Address - Phone:540-886-2956
Practice Address - Fax:540-213-8748
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410961390200000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program