Provider Demographics
NPI:1659628170
Name:C. EDMUND BURTON DDS PC
Entity Type:Organization
Organization Name:C. EDMUND BURTON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:718-756-7555
Mailing Address - Street 1:1185 DEAN STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-5607
Mailing Address - Country:US
Mailing Address - Phone:718-756-7555
Mailing Address - Fax:718-771-6007
Practice Address - Street 1:1185 DEAN STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-5607
Practice Address - Country:US
Practice Address - Phone:718-756-7555
Practice Address - Fax:718-771-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY160-990-7807Medicaid