Provider Demographics
NPI:1619208030
Name:S.J.BURROW,III.D.D.S.,M.S.,P.L.L.C.
Entity Type:Organization
Organization Name:S.J.BURROW,III.D.D.S.,M.S.,P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:BURROW
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:704-547-0803
Mailing Address - Street 1:2711 RANDOLPH RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2034
Mailing Address - Country:US
Mailing Address - Phone:704-334-7202
Mailing Address - Fax:704-372-2690
Practice Address - Street 1:10320 MALLARD CREEK RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-9756
Practice Address - Country:US
Practice Address - Phone:704-547-8438
Practice Address - Fax:704-372-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-25
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty