Provider Demographics
NPI:1538286281
Name:HAWTHORNE, BURNELL BRAGG (DDS)
Entity Type:Individual
Prefix:DR
First Name:BURNELL
Middle Name:BRAGG
Last Name:HAWTHORNE
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 1:8900 LIBERTY CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23030-3861
Mailing Address - Country:US
Mailing Address - Phone:804-829-5804
Mailing Address - Fax:
Practice Address - Street 1:7349 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7221
Practice Address - Country:US
Practice Address - Phone:757-564-8942
Practice Address - Fax:757-564-8667
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010058261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice