Provider Demographics
NPI:1568579662
Name:BURZYNSKI, CHARLES MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MATTHEW
Last Name:BURZYNSKI
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 1:1701 FOUR MILE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1940
Mailing Address - Country:US
Mailing Address - Phone:570-323-1900
Mailing Address - Fax:570-323-6079
Practice Address - Street 1:1701 FOUR MILE DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1940
Practice Address - Country:US
Practice Address - Phone:570-323-1900
Practice Address - Fax:570-323-6079
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019188L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT71915Medicare UPIN