Provider Demographics
NPI:1639281827
Name:GRIFFIN-BURRESS, BONCIEL LATRICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BONCIEL
Middle Name:LATRICE
Last Name:GRIFFIN-BURRESS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:BONCIEL
Other - Middle Name:LATRICE
Other - Last Name:GRIFFIN-BURRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4801 S LANGLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1515
Mailing Address - Country:US
Mailing Address - Phone:773-640-0533
Mailing Address - Fax:
Practice Address - Street 1:10019 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1925
Practice Address - Country:US
Practice Address - Phone:773-728-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-025726122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist