Provider Demographics
NPI:1801206370
Name:BURCH, KELLY ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:BURCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SLATE CREEK DR APT 9
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-2924
Mailing Address - Country:US
Mailing Address - Phone:585-278-8578
Mailing Address - Fax:
Practice Address - Street 1:24 SLATE CREEK DR APT 9
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-2924
Practice Address - Country:US
Practice Address - Phone:585-278-8578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY057971122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program