Provider Demographics
NPI:1598842890
Name:BURLESON, MICHAEL D (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:BURLESON
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:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-0929
Mailing Address - Country:US
Mailing Address - Phone:336-623-9143
Mailing Address - Fax:336-627-0948
Practice Address - Street 1:113 W ARBOR LN
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5305
Practice Address - Country:US
Practice Address - Phone:336-623-9143
Practice Address - Fax:336-627-0948
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991182Medicaid