Provider Demographics
NPI:1568584720
Name:BURGESS, HERBERT COLEMAN III (DDS)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:COLEMAN
Last Name:BURGESS
Suffix:III
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 1:1777 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6429
Mailing Address - Country:US
Mailing Address - Phone:910-762-1402
Mailing Address - Fax:910-762-8823
Practice Address - Street 1:1777 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6429
Practice Address - Country:US
Practice Address - Phone:910-762-1402
Practice Address - Fax:910-762-8823
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC54771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC91187OtherBLUE CROSS BLUE SHIELD
NC8991187Medicaid
NC91187OtherBLUE CROSS BLUE SHIELD