Provider Demographics
NPI:1568470680
Name:BURGESS, JOHN P (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:BURGESS
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 1:405 CAPITOL ST
Mailing Address - Street 2:THE PARLOR SUITE
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1749
Mailing Address - Country:US
Mailing Address - Phone:304-346-4820
Mailing Address - Fax:304-346-4842
Practice Address - Street 1:405 CAPITOL ST
Practice Address - Street 2:THE PARLOR SUITE
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1749
Practice Address - Country:US
Practice Address - Phone:304-346-4820
Practice Address - Fax:304-346-4842
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV27761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137189000Medicaid